Closing Perianal Fistulas Using a Laser: Long-Term Results in 103 Patients

Postoperative pain following laser fistula closure versus ligation of the intersphincteric fistula tract: A prospective double-blinded randomized controlled trial

BACKGROUND

Prior studies focus primarily on surgical outcomes of anal fistula treatment, such as healing rates, rather than patient-reported outcomes, such as postoperative pain, which could influence surgical choice.

OBJECTIVE

To compare pain scores at 6 and 24 h postoperatively between laser closure and ligation of the intersphincteric tract for anal fistula.

DESIGN

Prospective, double-blinded randomized controlled trial.

SETTINGS

A quaternary hospital in Malaysia.

PATIENTS

Patients aged 18-75 years with high transsphincteric fistulas.

INTERVENTION

Fistula laser closure versus ligation of the fistula tract (LIFT) treatment.

MAIN OUTCOME MEASURES

Pain scores, continence, quality of life (QOL), operative time, and treatment failure were compared using chi-square, Fisher's exact test, student t-test, or Mann-Whitney with p < 0.05 denoting statistical significance.

RESULTS

Fifty-six patients were recruited (laser, n = 28, LIFT, n = 28). Median pain scores for laser versus LIFT at 6 h postoperatively were 1.0 versus 2.0 (Rest, p = 0.213) and 3.0 versus 4.0 (Movement, p = 0.448), respectively. At 24 h, this reduced to 2.5 in both arms at rest (p = 0.842) but increased to 4.8 versus 3.5 on movement (p = 0.383). Median operative time for laser was significantly shorter (32.5 min) than LIFT (p < 0.001). Laser treated patients trended toward quicker return to work (10.5 vs. 14.0, p = 0.181) but treatment failure was similar (54% vs. 50%, p = 0.71). No patients developed postoperative incontinence. Mean SF-36 scores increased from baseline (67.1 ± 17.0; 95% CI 63.6-82.4 vs. 71.3 ± 11.4; 95% CI 64.0-75.0) to 6 months postoperatively (77.7 ± 21.0; 95% CI 57.0-80.3 vs. 74.0 ± 14.3; 95% CI 67.6-81.4) regardless of the type of surgery (P > 0.05).

LIMITATIONS

Patients with prior fistula surgery (approximately 20%) led to heterogeneity. The total laser energy delivered varied depending on fistula anatomy.

CONCLUSION

Laser fistula closure is an alternative to LIFT, with similar postoperative pain and shorter operative time despite more complex fistula anatomy in the laser arm, with a greater improvement in QOL.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06212739.

Protocol of the LATFIA trial (Laser Assisted Treatment of Fistula in Ano): a multicentre, prospective, randomized controlled trial comparing fistula-tract laser closure (FiLaC™) with rectal advancement flap for high trans-sphincteric fistulas

AIM

Anal fistula is one of the most common anal diseases, affecting between 1 and 3 per 10 000 people per year. Symptoms have a potentially severe effect on a patient's quality of life. Surgery is the mainstay of treatment, aiming to cure the fistula and preserve anal sphincter function. Rectal advancement flap (RAF) is currently the gold standard treatment but has recurrence rates varying between 20% and 50% and might lead to disturbance of continence. The aim of the trial described in this work is to discover if the minimally invasive fistula tract laser closure (FiLaC™) technique could achieve higher healing rates and a better functional outcome than RAF.

METHOD

We will perform a randomized prospective multicentre noninferiority study of the treatment of high trans-sphincteric perianal fistulas, comparing FiLaC™ with RAF in terms of fistula healing, recurrence rate, functional outcome and quality of life. Primary and secondary fistula healing will be evaluated at 26 and 52 weeks' follow-up. Quality of life will be evaluated using the SF-36 questionnaire, the Faecal Incontinence Quality of Life Scale questionnaire and the Vaizey score at 3, 6, 12 and 26 weeks postoperatively.

CONCLUSION

High trans-sphincteric fistulas have a potentially severe effect on a patient's quality of life. Classical treatment with RAF is a time-consuming invasive procedure. The LATFIA trial aims to compare FiLaC™ with the gold standard treatment with RAF. In case of noninferiority, FiLaC™ treatment could be standardized as a first line treatment for high trans-sphincteric fistulas. Better conservation of the patient's anal sphincter function could possibly be obtained. Likewise, we will report on the postoperative quality of life when applying these two techniques.

FiLaC® procedure for highly selected anal fistula patients: indications, safety and efficacy from an observational study at a tertiary referral center

BACKGROUND

the ideal clinical profile of patients or fistula features for fistula laser closure (FiLaC®) technique remain to be established. The aim of this study was to analyze clinical outcomes and the safety profile of FiLaC® in search for an ideal setting for this technique.

METHODS

a retrospective observational study was performed from a prospective database including all consecutive patients who underwent surgery for anal fistula (AF) with FiLaC® in the coloproctology unit of a tertiary referral center, between October 2015 and December 2021. The FiLaC® procedure was offered to AF patients who were considered to be at risk of fecal incontinence. Fistulas were described according to Parks' classification and categorized as complex or simple according to the American Gastroenterological Association (AGA) guidelines. Healing was defined by the closure of the internal and external openings for at least six months. Predictive factors of AF healing were investigated.

RESULTS

a total of 36 patients were included, with a mean age of 48 ± 13.9 years. Twenty patients (55.6 %) were male and 13 patients (36 %) had Crohn's disease (CD). Fourteen patients (38.8 %) had a complex fistula. The primary and secondary healing rates were 55.6 % and 91.7 %, respectively, during a median follow-up time of 12 months (IQR 7-29). No fecal continence impairment was registered in any case. The proportion of patients with primary healing was significantly higher in CD patients (76.9 % vs 43.5 %, p = 0.048).

CONCLUSIONS

FiLaC® is a sphincter-preserving procedure with an excellent safety profile and reasonable success rate despite of the strict patient selection. This technique may be attractive for patients with CD due to its higher primary healing rate.

Laser technology in proctological diseases: is it really the wave of the future?

Different types of lasers have been applied for various proctological conditions. We discuss about published articles regarding the application of lasers, with concern about evidence-based use of these techniques and technologies. We performed a literature search about laser treatments for proctological conditions. 55 studies were included for the final revision. Meta-analysis of data was not performed because of heterogeneity of study designs and outcome measures. A scoping review was performed. Laser treatments for hemorrhoids require a shorter operative time and show less postoperative pain and bleeding compared to conventional hemorrhoidectomy, but are more expensive. Studies are heterogeneous in design, endpoints, postoperative assessment, length of follow-up and outcome measures. Only 3 RCTs are available and only three studies evaluate long-term outcomes. FiLaC (fistula laser closure) was initially described in 2011 for the treatment of anal fistula. In the published studies the reported healing rates vary between 20 and 82%, and the ideal indication is yet to be defined. Studies with long-term follow-up are lacking. SiLaT (sinus laser treatment) applied the technology used for FiLaC to the treatment of pilonidal sinus disease. This technique had less perioperative pain and shorter hospital stay, but a lower primary healing rate when compared to traditional techniques. Available data is very limited, and no randomized trials are published to date. Laser assisted techniques are a viable, minimally invasive, but expensive option for the treatment of several proctological conditions. Further researches are needed to assess if patients could benefit of their use, and for what indication.

Emerging Treatments and the Clinical Trial Landscape for Hidradenitis Suppurativa-Part II: Procedural and Wound Care Therapies

Procedural treatments are a cornerstone of hidradenitis suppurativa (HS) management. New interventional therapies are being studied as part of the upsurge in HS research and clinical trials. Additionally, draining wounds can impart a significant negative impact on patients' quality of life, requiring daily dressing changes. However, standardized guidelines on how to best manage HS wounds both day-to-day and post-procedure are lacking. In part II of this emerging therapies review, procedural treatments and wound care dressings and devices that are being investigated for HS management are discussed.

Closure of Fistula-in-Ano Using a Radial-Emitting Laser Probe: Initial Experience in Lagos, Nigeria

Background

Fistula-in-ano treatment has remained quite challenging with high failure rates and a potential for damage to the anal sphincteric complex leading to flatal or faecal incontinence. The treatment of fistula-in-ano using the fistula laser closure (FiLaC) as a minimally invasive, sphincter-saving procedure for complex disease has recently been documented.

Objectives

This review aimed to report the outcome of using it at the Lagos University Teaching Hospital.

Patients and Methods

The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, type of fistula, duration of the procedures, and postoperative complications were evaluated.

Results

Eleven male patients had laser fistula-in-ano closure. The age range was 33-51 years, with a median age of 39 years and an interquartile range (IQR) of 37-47 years. Five patients were noted to have high fistula/e, whereas six had low fistula/e, seven had a single tract each, and three had three tracts each. The duration of surgery ranged, approximately from 3 to 60 min, with a median of 19 min and IQR of 9-33 min. Postoperative pain was mild in all patients and were all discharged as day case. There was no postoperative wound infection, anal incontinence, anal stenosis, and subcutaneous abscess. However, there was a recurrence in two patients.

Conclusions

FiLaC has been demonstrated to be a reliable and safe sphincter-saving procedure for treating fistula-in-ano even for complex and high fistulae that is feasible in our subregion.

The Current Clinical Trial Landscape for Hidradenitis Suppurativa: A Narrative Review

Hidradenitis suppurativa (HS) is a skin disease resulting from chronic, recurrent inflammation around hair follicles, characterized by proinflammatory cytokines such as IL-1, IL-17, IL-23, and TNF-α. While adalimumab, a TNF-α targeting human IgG monoclonal antibody, is the only approved treatment for HS, there are many other therapies being investigated now targeting other key players in inflammatory pathways such as the cytokines listed above, C5a in the complement pathway, and Janus kinase (JAK). This review discusses current clinical trials for biologics and small molecules, procedures, and wound dressings undergoing study in hidradenitis suppurativa.

Prospective and multicentre study of radiofrequency treatment in anal fistula

BACKGROUND

The most effective treatment for anal fistula is fistulotomy, but it involves a risk of anal incontinence. To reduce this morbidity, sphincter-sparing treatments have been developed, but their success in real life is often less than 50%. The aim is to determine the clinical healing rate 6 months after radiofrequency treatment.

METHODS

We planned to evaluate 50 patients from three French proctology centres. Treatment efficacy was evaluated at 6 and 12 months by means of clinical and magnetic resonance imaging examination. We evaluated morbidity and healing prognostic factors.

RESULTS

Fifty patients with a mean age of 51 years (22-82) were included. Eleven patients had a low trans-sphincteric fistula (LTS), 21 patients had a high trans-sphincteric fistula (HTS), eight had a complex fistula and nine had Crohn's disease fistula. After 6 months, 17 patients (34.7%) had a clinically healed fistula, including five (45.5%) with LTS fistula, seven (33.3%) with HTS fistula, one (12.5%) with complex fistula, four (44.4%) with Crohn's disease, with no significant difference between these fistula types (p: 0.142). At 12 months, the healing rate was identical. MRI in 15 out of 17 clinically healed patients showed a deep remission of 73.3% at 12 months. Energy power was associated with the success of the treatment. There was an 8.2% incidence of post-surgical complications with 4.1% being abscesses (one required surgical management). Postoperative pain was minor. No new cases or deterioration of continence have been shown.

CONCLUSION

Radiofrequency is effective in 34.7% of the cases as an anal fistula treatment in this first prospective study, with low morbidity and no effect on continence. Clinical healing was deep (MRI) in three-quarters at 1 year. The increase in energy power during the procedure seems to be a key point to be analysed to optimise results.

Treatment of cryptoglandular fistulas with the fistula tract laser closure (FiLaC™) method in comparison with standard methods: first results of a multicenter retrospective comparative study in the Netherlands

BACKGROUND

Current surgical closure techniques for sphincter-sparing treatment of high cryptoglandular fistulas in the Netherlands include the mucosal advancement flap procedure (MAF) and ligation of the intersphincteric fistula tract (LIFT). A relatively novel treatment is the fistula tract laser closure (FiLaC™) method. The aim of this study was to investigate the differences in healing and recurrence rates between FiLaC™ and current standard practices.

METHODS

This multicenter retrospective cohort study included both primary and recurrent high cryptoglandular anorectal fistulas, treated with either FiLaC™ or standard methods (MAF or LIFT) between September 2015 and July 2020. Patients with extrasphincteric fistulas, Crohn's disease, multiple fistulas, age < 18 years or missing data regarding healing time or recurrence were excluded. The primary outcomes were the clinical primary and secondary healing and recurrence rates. Primary healing was defined as a closed external opening without fluid discharge within 6 months of treatment on examination, while secondary healing was the same endpoint after secondary treatment. Secondary outcomes included healing time and complaints.

RESULTS

A total of 162 high fistulas from 3 Dutch hospitals were included. Ninety-nine high fistulas were treated with FiLaC™ and 63 with either MAF or LIFT. There were no significant differences between FiLaC™ and MAF/LIFT in terms of clinical healing (55.6% versus 58.7%, p = .601), secondary healing (70.0% versus 69.2%, p = .950) or recurrence rates (49.5% versus 54%, p = .420), respectively. Median follow-up duration was 7.1 months in the FiLaC™ group (interquartile range [IQR] 4.1-14.4 months) versus 6 months in the control group (IQR 3.5-8.1 months).

CONCLUSIONS

FiLaC™ treatment of high anorectal fistulas does not appear to be inferior to MAF or LIFT. Based on these preliminary results, FiLaC™ can be considered as a worthwhile treatment option for high cryptoglandular fistulas. Prospective studies with a longer follow-up period and well-determined postoperative parameters such as complication rates, magnetic resonance imaging for confirmation of fistula healing, incontinence and quality of life are warranted.

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.

Treatment of anal fistula with FiLaC®: results of a 10-year experience with 175 patients

BACKGROUND

Treatment of fistula-in-ano with fistula laser closure (FiLaC^®) is a sphincter-saving procedure indicated for patients with complex anal fistulas. The aim of our study was to evaluate the clinical results of a 10-year experience with FiLaC^®.

METHODS

Data from patients with cryptoglandular anal fistula who underwent laser closure with FiLaC^® in June 2009-May 2019 were evaluated. The primary study endpoint was healing rate. Secondary endpoints were evaluation of morbidity and assessment of possible predictive factors of failure.

RESULTS

Out of a total of 180 patients, 5 had been lost to follow-up. 175 patients [m:f: 115:60; median age 49 years (range18-81 years)] with cryptoglandular fistulas treated with FiLaC^® were included in the study. Fistulas were transphincteric in 152 (86.8%) cases, intersphincteric in 18 (10.3%), and suprasphincteric in 5 (2.9%). A seton or draining silicon loop was placed in 142 (81.8%) patients at a median of 14 weeks (range10-28 weeks) prior to FiLaC^®. At median follow-up of 60 months (range 9-120 months), the overall primary healing rate was 66.8% (117/175). Thirty-eight patients (21.7%) failed to heal. Twenty out of 175 (11.4%) patients had recurrence at median follow-up of 18 months (range 9-50 months). Patients in whom a seton/loop was inserted for drainage at the first-stage procedure had a statistically significant higher rate of success (100/142, 70.4% vs. 17/33, 51.5%, respectively; p 0.0377; odds ratio 0.45). Forty-eight patients were reoperated on at a median of 15 months (range 12-20 months) after laser treatment. Twenty-six underwent redo laser closure with FiLaC^®, and 12 of them healed (46%), for a secondary success rate of 73.7%.

CONCLUSIONS

Longer follow-up confirms the efficacy of FiLaC^® in the treatment of complex anal fistulas. Its use and implementation should be encouraged.

Laser treatment of pilonidal disease: a systematic review

Pilonidal disease (PD) is a common condition, and there is still an ongoing debate on ideal management that should be minimally invasive, safe, and efficient. The use of radially emitting laser in the treatment of chronic PD is a novel minimally invasive technique, and initial studies with a small number of patients showed promising results. This study aimed to assess the efficacy and safety of chronic PD treatment with a laser using a systematic review of the published literature. A systematic review was conducted after PubMed, Scopus, Embase, Web of Science, and the Cochrane database search for studies reporting laser treatment of chronic PD. Also, our unpublished prospective single-center study was included in this review. Ten of 87 studies were eligible for the review, including 971 patients. The median age of the patients was 26 (range 13-68), and the median operative time was 26 (range 6-65) min. With a median follow-up of 12 (range 7-25) months, 917 (94.4%) patients achieved primary healing with a weighted mean recurrence rate of 3.8%. The weighted mean complication rate was 10% (95% CI 5.7-14.3%, I2 = 82.28, p < 0.001), and all were minor. The published literature demonstrates that laser treatment is a promising procedure in the management of chronic PD. Furthermore, the review showed that standardized operative techniques and perioperative steps were used. The results were limited to the mild chronic PD. Classification of PD severity and standardized outcome reporting is required to define indications and contraindications for laser PD treatment. Randomized controlled trials are needed to determine the long-term effectiveness and superiority of laser treatment over other methods.

EFFICACY OF LOW-LEVEL LASER THERAPY ON FISTULA-IN-ANO TREATMENT

Background:

Treating anal fistulae is still a great challenge due to the possibility of fecal incontinence after surgery and that the use of laser has been gaining space in medicine, including as an inducing method of healing.

Aim:

To evaluate the efficacy of low-level laser therapy on fistula-in-ano treatment in rats.

Methods:

Fifteen male Wistar rats weighing approximately 250-300g were used, which were subjected to the anal fistula induction procedure and after 30 days were distributed into two groups: control group (CG, n=5) and laser group (LG, n=10) observed for another 30 days. In the CG no treatment was performed and, in the LG, low-level laser therapy was applied in fistulous tracts daily. The closure of the fistulous tract, the area of the remaining tract, the inflammatory infiltrate and vascular congestion were evaluated.

Results:

There was no complete closure of the tract in any of the animals. The mean area of the remaining tract was 847.2 µm² in the CG and 248.5 µm² in the LG (p=0.001). The mean inflammatory infiltrate score was 2.4 in the CG and 1.3 in the LG (p=0.0285), while in the evaluation of vascular congestion, 1.6 was observed in the CG and 0.6 in the LG (p=0.031).

Conclusions:

Low-level laser therapy was able to reduce the area of the fistulous tracts as well as decrease the inflammatory process and local vascular congestion.

The REALISE score: a new statistically validated scoring system to assess the severity of anal fissures

BACKGROUND

Anal fissure (AF) is a common, painful disease that strongly affects patients' quality of life, however, no scoring system to assess the severity of AF is available in the literature. The aim of this study was to set up and validate a reliable scoring system to quantify the severity of AF, to be used in prospective trials comparing the efficacy and the outcomes of surgical or medical treatments.

METHODS

The study was conducted on patients with acute or chronic AF and a control group in a tertiary centre for coloproctology in June 2020-September 2020. Two researchers independently carried out a structured interviewer-led questionnaire at two different time points (T1/T2). The questionnaire consisted of five items selected according to the most commonly reported symptoms for AF: the item pain, was scored from 0 to 10 using a visual analogue scale, and quality of life, duration of pain, use of painkillers, and bleeding were scored from 1 to 5 using Likert-scale questions. The scoRing systEm for AnaL fIsSurE (REALISE) score was the sum of the points. Patients with AF and a control group of patients with haemorrhoids, anal fistula, or obstructed defecation syndrome entered the study. Main outcome measures were reliability, inter-/intraobserver agreement, and repeatability.

RESULTS

One hundred and fifty well-matched patients (75 with AF and 75 controls) were enrolled. A significant difference was found between the mean REALISE score for patients with AF and controls (p < 0.001). The two REALISE scores were highly correlated (r = 0.99). The coefficient of repeatability was 1.45 in T1 and 1.18 in T2.

CONCLUSIONS

The REALISE score may have an important role in the assessment and management of AF, in grading the severity of AF and comparing results of different treatments.

Retrospective Analysis of Primary Suturing of the Internal Orifice of Perianal Fistula During FiLaC Procedure

PURPOSE

We aimed to evaluate the results of the fistula-tract laser closure associated with primary closure of internal orifice.

MATERIALS AND METHODS

The surgical objective was to seal the fistula tract using laser energy and closing internal orifice with purse-string suture. Between January 2017 and December 2018, 35 consecutive patients who underwent the laser closure plus internal orifice suturing included. In all 35 patients, the laser procedure was applied then internal orifice was primarily closed with 2-0 polyglactin suture after the debridement of necrotic tissue.

RESULTS

Among 35 patients (11 female, 24 male), mean age was 43.9±12.9 years. Median follow-up was 11 months (6.0 to 17.6 mo). According to the Park classification; 21 patients (60%) had intersphincteric fistula, 12 (34%) had transsphincteric fistula, 2 (6%) had suprasphincteric or extrasphincteric fistula. There were low/simple and high/complex fistula in 21 (60%) and 14 patients (40%), respectively. Overall, 15/35 (42.9%) patients showed complete healing, 12/35 (34%) had slight drainage with minimal symptoms, 8/35 (22%) patients had persistent symptomatic drainage, and there was no patient with painful symptomatic drainage. On the basis of the Jorge-Wexner continence score, there was no significant difference in patients before and after the procedure. The perfect continence rate was achieved in 32 patients (91%).

CONCLUSION

Although the absence of major and minor complications after Fistula Laser Closure (FiLaC) procedure seemed to be a major advantage, we thought that closure of the internal opening by primary suturing has no positive effect on the healing of the perianal fistula.

Simple fistula-in-ano: is it all simple? A systematic review

Background

Simple anal fistula is one of the most common causes of proctological surgery and fistulotomy is considered the gold standard. This procedure, however, may cause complications. The aim of this systematic review was to assess the surgical treatment of simple anal fistula with traditional and sphincter-sparing techniques.

Methods

A literature research was performed using PubMed, Cochrane, and Google Scholar to identify studies on the surgical treatment of simple anal fistulas. Observational studies and randomized clinical trials were included. We assessed the risk of bias of included studies using the Jadad scale for randomized controlled trials, and the MINORS Scale for the remaining studies.

Results

The search returned 456 records, and 66 studies were found to be eligible. The quality of the studies was generally low. A total of 4883 patients with a simple anal fistula underwent a sphincter-cutting procedure, mainly fistulotomy, with a weighted average healing rate of 93.7%, while any postoperative continence impairment was reported in 12.7% of patients. Sphincter-sparing techniques were adopted to treat 602 patients affected by simple anal fistula, reaching a weighted average success rate of 77.7%, with no study reporting a significant postoperative incontinence rate. The postoperative onset of fecal incontinence and the recurrence of the disease reduced patients’ quality of life and satisfaction.

Conclusions

Surgical treatment of simple anal fistulas with sphincter-cutting procedures provides excellent cure rates, even if postoperative fecal incontinence is not a negligible risk. A sphincter-sparing procedure could be useful in selected patients.

Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis

AIM

Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease.

METHOD

The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019.

RESULTS

Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study.

CONCLUSION

FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.

Sphincter-saving therapy for fistula-in-ano: long-term follow-up after FiLaC®

BACKGROUND

The treatment of anal fistula remains a challenge between maintaining continence and radical surgery to prevent recurrence. Fistula-tract Laser Closure (FiLaC^®) is a sphincter-saving technique using a radial emitting laser fibre to close the fistula tract. The aim of this study was to report long-term outcomes in patients who received FiLaC^® therapy for transsphincteric and intersphincteric anal fistula between January 2011 and December 2017.

METHODS

A retrospective study was performed on patients who were treated with FiLaC^®- for a transsphincteric and intersphincteric anal fistula at our institution between January 2011 and December 2017. In all patients, the FiLaC^® procedure was combined with a closure of the internal orifice using a simple 3-0 Z stitch. Patient characteristics, previous proctological history, healing rates, failures and postoperative continence were investigated.

RESULTS

The study included 83 patients [mean age 50.01 ± 14.59 years. 64 (77.1%) males] with a mean follow-up period of 41.99 (± 21.59) months (range 4-87 months). Thirteen patients (15.7%) had a recurrent fistula. 65 patients (78.3%) had undergone prior abscess drainage with insertion of a seton. The primary healing rate was 74.7% (62 of 83 patients) overall. Eleven (13.3%) of the 21 patients (25.3%) who failed FiLaC^®-therapy underwent a second operation. In eight cases, Re-FiLaC^® and in three cases, fistulectomy with closure of the internal orifice was performed. Afterwards 6 (54.5%) of these 11 patients could be considered cured: 3 who had fistulectomy and three who had Re-FiLaC^® treatment. The overall healing rate after second FiLaC^® was 78.3% (65 of 83 patients) while the overall healing rate for FiLaC^® therapy combined with any second procedure was 81.9% (68 of 83 patients). The follow-up period in this group of 11 patients who received re-operation was 38 months (range 13-84 months). Changes in continence occurred in eight patients (9.6%). No patient reported major incontinence postoperatively.

CONCLUSIONS

The FiLaC^® procedure is associated with good healing rates in long-term follow-up and should be considered as a treatment option for transsphincteric and intersphincteric anal fistulae, especially due to the low complication rate and low risk of sphincter injury.

Long-term Outcomes of Laser Ablation of Fistula Tract for Fistula-in-Ano: A Considerable Option in Sphincter Preservation

BACKGROUND

Ablation of anal fistula tract using a radial laser-emitting probe is a sphincter-preserving technique.

OBJECTIVE

The purpose of this study was to assess long-term outcomes of laser ablation of fistula tract.

DESIGN

This was a retrospective analysis of the long-term outcomes of 100 patients who underwent laser ablation of fistula tract.

SETTINGS

This was a single-center study from a tertiary center in Turkey.

PATIENTS

All of the patients with fistula-in-ano were included. Exclusion criteria were the presence of perianal abscess, underlying Crohn's disease, fistula tract <2 cm, fistulas suitable for simple fistulotomy, and intersphincteric fistulas originated from posterior located chronic anal fissure.

INTERVENTIONS

A probe housing a 15-watt laser emitting at a wavelength of 1470 nm and an energy level of 100 to 120 joule/cm was used.

MAIN OUTCOME MEASURES

No discharge, no symptoms, and fibrotic scar on skin where previously an external opening was present were defined as overall complete healing. All results other than overall complete healing were accepted as failure.

RESULTS

A total of 100 patients underwent laser ablation of fistula tract with a median age of 42 years (range, 21-83 y). The majority of them were men. The overall success rate was 62% (95% CI, 52%-71%) in a median follow-up time of 48 months (range, 6-56 mo). None of the patients experienced permanent major or minor anal incontinence.

LIMITATIONS

The retrospective nature of this study is its main limitation. Other limitations consist of phone interview for follow-up of the majority of the patients, single-institution data, and the relatively small number of patients.

CONCLUSIONS

Laser ablation of the fistula tract is a sphincter-preserving procedure with an acceptable long-term success rate. See Video Abstract at http://links.lww.com/DCR/B186. RESULTADOS A LARGO PLAZO DE LA ABLACIóN CON LáSER DEL TRACTO EN LA FíSTULA ANAL: UNA CONSIDERABLE OPCIóN EN LA PRESERVACIóN DEL ESFíNTER: La ablación con una sonda radial emisora de láser del tracto de fístula anal, es una técnica de preservación del esfínter.Evaluar los resultados a largo plazo de la ablación con láser del tracto fistuloso.Análisis retrospectivo de los resultados a largo plazo de 100 pacientes que se sometieron a la ablación con láser del tracto de fístula.Este es un estudio de centro único de un centro terciario en Turquía.Fueron incluidos todos pacientes con fístula anal. Los criterios de exclusión fueron la presencia de absceso perianal, enfermedad de Crohn subyacente, tracto de fístula menor de 2 cm, fístulas adecuadas para fistulotomía simple y fístulas interesfintéricas originadas en una fisura anal crónica posterior.Se utilizó una sonda que alberga un láser de 15 vatios que emite a una longitud de onda de 1,470 nm y un nivel de energía de 100-120 julios / cm.Sin secreción, sin síntomas y la cicatriz fibrótica en la piel, donde anteriormente estaba presente la apertura externa, se definió como "curación completa general." Todos los resultados que no sean "curación completa en general" se aceptaron como fracaso.Cien pacientes fueron sometidos a ablación con láser del tracto de fístula anal, con una edad media de 42 (21-83) años. La mayoría de ellos fueron varones. La tasa de éxito general fue del 62% (intervalo de confianza del 95%, 52%-71%) en una mediana de tiempo de seguimiento de 48 (6-56) meses. Ninguno de los pacientes experimentó incontinencia anal mayor o menor permanente.La naturaleza retrospectiva de este estudio es su principal limitación. Otras limitaciones consisten en una entrevista telefónica para el seguimiento de la mayoría de los pacientes, datos de una sola institución y un número relativamente pequeño de pacientes.La ablación con láser del tracto de la fístula anal, es un procedimiento de preservación del esfínter y con una aceptable tasa de éxito a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B186. (Traducción-Dr Fidel Ruiz Healy).

Laser ablation of fistula tract (LAFT) and complex fistula-in-ano: "the ideal indication" is becoming clearer…

BACKGROUND

An initial study enabled us to achieve 60% healing of high transsphincteric fistula-in-ano with laser ablation of fistula tract (LAFT) The purpose of this new study was to investigate other predictors of the success of this technique in the treatment of complex anoperineal fistulas.

METHODS

All patients treated with LAFT in our department between May 2017 and October 2018 were included prospectively. LAFT was used for patients with complex anoperineal fistulas who were at high risk of anal incontinence after fistulotomy. The fistula was considered healed when the internal and external openings were closed and the patient experienced no pain or leakage.

RESULTS

A total of 100 consecutive patients (65 males) with a median age of 43 years (range 22-88 years) were included in the study. Eight patients were lost to follow-up. The fistulas were low (8%) or high (79%) transsphincteric, and suprasphincteric (13%). After a median follow-up of 13.6 months (range 6-23 months), fistula healing was observed in 41 patients (44.6%). On univariate analysis, an anterior location, a narrow internal orifice and administration of less than 400 J of energy were significantly associated with healing. On multivariate analysis, a narrow internal orifice and low energy administration remained significant predictive factors of success [OR 5.08 (1.03-25.03), p = 0.046; OR 2.59 (1.08-6.17), p = 0.032]. No new cases of anal incontinence or any worsening of pre-existing anal incontinence was observed during follow up.

CONCLUSIONS

This study indicates that complex anoperineal fistulas with a narrow internal orifice can be successfully treated with less than 400 J and are ideal for LAFT.

A systematic review and meta-analysis of the safety and efficacy of fistula laser closure

BACKGROUND

Fistula laser closure (FiLaC) is a novel sphincter-saving technique for the treatment of fistula-in-ano. The aim of this study was to assess the safety and efficacy of the FiLaC procedure.

METHODS

Databases including PubMed/Medline, Scopus, Web of Science, and Embase were searched for articles assessing FiLaC. All studies including case series and comparative studies reporting the outcome of FiLaC in the treatment of fistula-in-ano were considered eligible. The main outcomes were healing rates of fistula laser closure, postoperative complications including incontinence, technical aspects of the procedure and failure of healing.

RESULTS

Seven studies were included. There were a total of 454 patients, 69.1% with a transsphincteric fistula-in-ano and 35% with recurrent disease. The median age of the patients was 43 years (range 18-83 years). The median operation time was 18.3 min (range 6-32 min). With a median follow-up of 23.7 months, the weighed mean rate of primary healing was 67.3% and the overall success when FiLaC was reused was 69.7%. The weighted mean rate of complications was 4%, all of them were minor complications and the weighted mean rate of continence affection was 1% in the form of minor soiling.

CONCLUSIONS

FiLaC may be considered an effective and safe sphincter-saving technique for the treatment of fistula-in-ano with an acceptable, low, complication rate. However, well-designed randomized control trials comparing FiLaC with other techniques are required to substantiate the promising outcomes reported in this review.

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.

Implementation of laser ablation of fistula tract (LAFT) for perianal fistulas: do the results warrant continued application of this technique?

BACKGROUND

Laser Ablation of Fistula Tract (LAFT) is a novel technique for the treatment of perianal fistulas. Initial reports have shown moderate-to-good results. The aim of this study was to evaluate this implementation and the effectiveness of this technique. Patients were offered LAFT as a treatment option for their perianal fistulas at the outpatient clinic between November 2016 and April 2018. Inclusion criteria were intersphincteric and transsphincteric fistula of cryptoglandular origin [10]. Exclusion criteria were supra- or extrasphincteric fistula, Crohn's disease, presence of undrained collections or side tracts and malignancy-related fistula. The primary outcome was fistula healing rate, the main secondary outcome incidence of postoperative fecal incontinence. Healing and postoperative FISI were evaluated at our outpatient clinic during follow-up at 6 and 12 weeks. A questionnaire was sent to all patients to evaluate the long-term postoperative FISI and patient satisfaction after 3 months.

RESULTS

Between November 2016 and April 2018, 20 patients [m:f = 4:16, median age 45 (27-78) years] underwent LAFT. Median follow-up was 10 months (IQR 7.3 months). A draining seton was placed in 15 (75%) of all patients with a median time of 12 weeks (IQR 14 weeks) prior to LAFT. Five intersphincteric and 13 transsphincteric fistulas were treated. Overall healing rate was 20% (4/20). The median postoperative fecal incontinence severity index (FISI) score was 0 (range 0-38); however, we found a change in continence in 39% of the patients.

CONCLUSIONS

LAFT has now been discontinued as a treatment of cryptoglandular perianal fistulas in our centre, because of its disappointing results. Further detailed research seems to be warranted to investigate its exact indication and limitations.

The optimal indication for FiLaC® is high trans-sphincteric fistula-in-ano: a prospective cohort of 69 consecutive patients

BACKGROUND

The aim of our study was to prospectively evaluate the effectiveness of the Fistula Laser Closure (FiLaC^®) technique in patients at high risk of anal incontinence and to determine the predictors of success and the impact of the procedure on anal continence.

METHODS

A prospective study was conducted on all patients treated with FiLaC^® in our department in May 2016-April 2017, because they were at high risk of anal incontinence after fistulotomy, The fistula was considered healed when the internal and external openings were closed and the patient experienced was no pain or leakage.

RESULTS

A total of 69 consecutive patients (34 males) with a median age of 40 years (33-53 years) were included in the study. One patient was lost to follow up. The fistulas were intersphincteric (3%), low (15%) or high (66%) trans-sphincteric, and suprasphincteric (16%). After a median follow-up period of 6.3 months (4.2-9.3), fistula healing was observed in 31 patients (45.6%). In univariate analysis, high trans-sphincteric fistulas (p = 0.007) and age over 50 years (p = 0.034) were significantly associated with healing. In multivariate analysis, only high trans-sphincteric fistulas were a predictive factor of significant success. No new cases of anal incontinence or any worsening in case of pre-existing anal incontinence were observed during follow-up.

CONCLUSIONS

FiLaC^® is particularly effective in cases of high trans-sphincteric fistulas (60% cure). This technique seems to be the most promising sphincter-saving technique available for this indication.

Photodynamic Therapy for the Treatment of Complex Anal Fistula

BACKGROUND AND OBJECTIVES

To validate and analyze the results of intralesional photodynamic therapy in the treatment of complex anal fistula.

STUDY DESIGN/MATERIALS AND METHODS

This prospective multicentric observational study enrolled patients treated for complex anal fistula who underwent intralesional photodynamic therapy (i-PDT). The included patients were treated from January 2016 to December 2018 with a minimum follow-up of 1 year to evaluate recurrence, continence and postoperative morbidity. Intralesional 5-aminolevulinic acid (ALA) gel (2%) was injected directly into the fistula. The internal and external orifices were closed. After an incubation period of 2 hours, the fistula was irradiated using an optical fiber connected to a red laser (Multidiode 630 PDT) operating at 1 W/cm for 3 minutes (180 J).

RESULTS

In total, 49 patients were included (61.2% male). The mean age was 48 years, and the mean duration of fistula was 13 months. Of the fistulas included, 75.5% were medium transphincteric, and 24.5% were high transphincteric. The median fistula length was 4 ± 1,14 cm (range: 3-5). A total of 41 patients (83.7%) had a previous history of fistula surgery. Preoperatively, some degree of anal incontinence was found in 5 patients (10.2%). No center reported any other procedure-related complications intraoperatively. Phototoxicity was found in one patient. In the first 48 hours after the procedure, fever was reported in 2 patients (4%). At the end of follow-up, total healing was observed in 32/49 patients (65.3%). No patient reported new incontinence postoperatively.

CONCLUSION

i-PDT could be considered a good choice in patients with complex anal fistulas to avoid surgery and its complications. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Advances in Perianal Disease Associated with Crohn's Disease-Evolving Approaches

Perianal diseases, common complications of Crohn's disease, are difficult to diagnose/manage. Patients with perianal Crohn's disease suffer from persistent pain and drainage, recurrent perianal sepsis, impaired quality of life, and financial burden. Conventional medical and surgical therapies carry risk of infection, myelosuppression, incontinence, disease recurrence. Although the phenotype of Crohn's disease has been extensively studied, reported outcomes are inconsistent. Endoanal ultrasonography is also becoming popular because of low cost and ability to acquire images in real time. Emerging management strategies for treatment including laser therapy, local injection of agents, use of hyperbaric oxygen, and stem cell therapy, have demonstrated efficacy.

[Quality indicators in the treatment of anal fistulas]

Anal fistulas are a common anorectal disease and are frequently associated with a perianal abscess. The etiology is based on a cryptoglandular infection in the intersphincteric space. Surgery remains the only definitive therapy. The primary goal of definitive fistula surgery is healing; however, success of fistula surgery is influenced by a variety of factors including the surgeon's experience, type of fistula, involvement of sphincter muscles, type of surgical procedure and patient-related factors. For the surgical treatment of a complex anal fistula, a variety of operative procedures have been described including fistulectomy with sphincterotomy, different flap procedures (e.g. mucosal flap and advancement flap) and finally so-called sphincter-preserving techniques, such as LIFT (ligation of intersphincteric fistula tract), VAAFT (video-assisted anal fistula treatment), the use of plugs of collagen or fibrin glue sealants as well as laser procedures or the clip. In the search for suitable quality indicators in anal fistula surgery there is a conflict between healing and preservation of continence. If potential quality indicators are identified the principles of anal fistula surgery must be adhered to and the appropriate selection of patients and procedures is of crucial importance to achieve high healing rates without compromising continence or inducing surgical revision due to abscesses or recurrence. Based on the available literature and guidelines, in the assessment of quality indicators considerable differences exist with respect to patient selection, etiology of anal fistulas and length of follow-up. Heterogeneity of treatment protocols lead to difficulties in a definitive assessment of which surgical treatment is the best option for complex anal fistulas.