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406 P. Meinero
to the internal opening, in order to well expose the internal opening at the level of the
muscle layer by lifting the overlaying mucosae. The supporting area of the mesh at
the muscle layer should be the widest possible, at least 2.5 square centimeters. A
patch of biological mesh is trimmed to fit the area of the defect. The mesh is carefully
stretched out on the muscular layer and fixed in place with three or four separate
stitches (PDS or Monocryl 3/0), making sure that a tension-free mesh fixation is
achieved. Subsequently, mucosal repair is completed with a few stitches (PDS or
Monocryl 2 or 3/0) (Fig. 17).
5.4 Autologous Dermis Graft
Approximately 2 years ago, we have been proposing an additional and promising
method to close the internal opening. Considering that before starting the
fistuloscopy at the beginning of the diagnostic phase, we have to enlarge the external
opening(s) by remo ving a little bit of its surrounding skin to facilitate insertion of the
fistuloscope, an autologous dermis graft of adequate size is harvested from the
outermost margin of the external opening (Fig. 18a).
The mucosae is incised at the internal opening and elevated to expose the
underlying inner muscular layer, and therefore the internal opening too. A single
Fig. 18 A dermis graft is harvested from the skin of the external opening margin (a). A stitch is
placed on the graft (b), which is fixed into the internal opening on the muscle layer (c, d)
25 VAAFT 407
stitch (PDS or Monocryl 3/0) is passed through the dermis graft (Fig. 18b), and
then secured over the inner muscular layer precisely on the inner opening
(Figs. 18c, d). The autologous dermis graft, which acts both as a barrier and
scaffold for tissue repair, provides for an airtight closure of the internal opening
(Meinero, 2021). If the latter is bigger, the graft must be wider, and more separate
stitches will be necessary to fix it t o the muscle layer. A thorough hemostasis must
be done before closing the overlying mucosae. The latter is finally repaired and
well closed with separate stitches (PDS or Monocryl 2 or 3/0). In the case this
method is chosen to closing the internal opening, a combination of antibiotics such
as metronidazole and ciprofloxacin is given the patient at home over a period of
7 days after surgery.
5.4.1 VAAFT Associated to the LIFT Procedure
The ligation with the contemporary interruption of the fistula tract in the inte rsphincteric space, rather than into the anal canal, seems to be a good option when
the internal opening is surrounded by scar and tough tissue in cases of fistula
recurrences (Rojanasakul et al., 2007). This procedure can be easily applied if the
fistula is not too deep. The fistula tract included in the inter-sphincteric space is not
involved in the scaring process, so that it can be easily treated before entering the
anal canal. Once VAAFT procedure is completed, a small incision on the anal edge
allows to discover the fistula in the inter-sphincteric space. The fistula ligation and its
interruption allows a good closure of the internal orifice. We currently use this
method in about 15% of cases.
5.5 Postoperative Management
All patients are given an information brochure on the postoperative management in
addition to the discharging letter, the medical record, and the DVD containing the
entire operation. The patient is asked to keep open the external opening for at least
4 weeks after surgery by doing irrigations with saline solution using a syringe,
twice a day. Thus, this maneuver lets the secretions to flowing-out through the
external opening(s), and allow to always keep clean the treated area. After 2 or
3 weeks, the patient can stop doing irrigation with saline solution, but is asked to
keep open the external opening skin only, so allowing the progressive closure of
the deepest part of the fistula tract. Notice how these dressings are done at patient’s
home with evident time and money s aving. Some painkiller are given the patient
depending on the pain level. Usually, the paracetamol is enough. Occasionally,
severe pain may require a stronger analgesic such as ketorolac or diclofenac. In
case of constipation, in order t o facilitate the evacuation of soft stools, a mild
laxative can be prescribed, just to avoid the straining on the suture in the anal canal.
Our post-op care foresees a first check consultation after 4 or 5 weeks after surgery,
unless complications. We set a 1, 3, 6, 12, and 24 m onth foll ow-up. Pat ients
coming from abroad or living far away are followed up with WhatsApp and
teleconsultations.
408 P. Meinero
6 Discussion
Over the last decade, various minimally invasive techniques have been developed
for treating complex anal fistulas, including fibrin glue, fistula plug, fistula laser
closure (FiLaC), and ligation of inter-sphincteric fistula tract (LIFT). However, the
outcomes are still not fully satisfactory, with a widely reported healing rate from
14% to 83%. It has been suggested that omission of the internal opening or
secondary tracts in surgery is the major factor in fistula recurrence (Liu et al.,
2020). The rationale of the VAAFT technique is based on the same principles as
other procedures for closing the internal opening and obliterating the tract, where the
real innovation is the precise identification of the fistula anatomy and the internal
opening by fistuloscopy and fulguration of the tract walls under direct vision. This
approach allows the identification and treatment of all the secondary tracts and the
abscess cavities connected to the main pathway. Some anal fistulas follow a tortuous
course between external and internal openings. For example, some trans-sphincteric
tracts arise laterally and run in a relatively straight course cephalad before turning
through a right angle in the inter-sphincteric space, horseshoeing around to the
6o’clock position, where they turn through a second right angle to run anteriorly
into the internal opening In these cases, the use of the rigid probe, commonly used
before starting a traditional technique, might lead to a risk of iatrogenic injury or a
false tract formation (Tozer et al., 2019). From that, the fundamental role of the
fistuloscope can be well understood.
We believe that the adoption of fistuloscopy together with a good technique for
closing the internal opening is the most effective way of achieving a high healing
rate for complex anal fistulas with preservation of the anal sphincters (Meinero &
Mori, 2011; Schwandner, 2013; Meinero et al., 2014; Adegbola et al., 2017; Garg &
Singh, 2017; Emile et al., 2018; Seow-En et al., 2016; Walega et al., 2014). In the
literature, there are many papers reporting that compared with other minimally
invasive techniques, VAAFT is the only procedure that allows intraoperative visualization of the entire fistula main tract, possible secondary tracts and the internal
fistula opening from within (Meinero, 2021; Liu et al., 2020; Meinero & Mori, 2011;
Schwandner, 2013; Meinero et al., 2014; Adegbola et al., 2017; Garg & Singh, 2017;
Emile et al., 2018; Seow-En et al., 2016; Walega et al., 2014; Zheng et al., 2018;
Jiang et al., 2017; Kochhar et al., 2014; Yao et al., 2021
Regusci et al., 2020). These peculiar characteristics make VAAFT an important
option for treating complex anal fistulas even in patients suffering from Crohn’s
disease. A recent study of the St. Mark’s Hospital demonstrates feasibility, safety,
and importantly an improvement in patient-reported outcomes in a series of patients
undergoing VAAFT for complex Crohn’s anal fistula. VAAFT reduces the main
symptoms (pain and discharge) in patients with complex refractory anal fistulas
(Adegbola et al., 2018 ). In patients suffering from Crohn’s disease with multiple anal
fistulas, VAAFT technique combined with the advancement flap repair, leads to a
high identification rate of occult side tracts with encouraging short-term healing rates
(Schwandner, 2013). In our experience, the outcomes indicate that VAAFT procedure is effective and safe for the treatment of complex fistula-in-ano and their
; Rojanasakul et al., 2007;
25 VAAFT 409
Fig. 19 VAAFT learning curve
recurrences. The acceptable healing rates, the very high level of patient satisfaction
and of postoperative quality of life, and the absence of functional sphincter impairment encouraged us to adopt this approach in all cases of anal fistula not suitable for
lay open/direct sphincter repair (Meinero et al., 2014; Adegbola et al., 2017).
VAAFT is not easy to perform, and an adequate training is necessary. According
to our experience, the learning curve should be at least of 60 surgeries. From the
literature arises that the higher the number of VAAFT performed, the greater the
success rate (Fig. 19).
In fact, the best results after adopting VAAFT procedure have been obtained by
surgeons who have done an adequate training.
As regards the results, it must be said that the literature reports homogeneous
outcomes fairly stable over time. Recent systematic reviews are confirming our
current success rate attested to be between 67% and 82% (Table 1) (Adegbola
et al., 2017) (Garg & Singh, 2017; Emile et al., 2018).
Anyway, the good result is depending on an adequate closure of the internal
opening, that remains an essential condition for avoiding recurrences (Seow-En
et al., 2016). In a more recent literature, we can find some authors who suggest to
combine VAAFT with FiLaC procedure reporting a better success rate (Yao et al.,
2021). However, in our experience, it doesn’t offer significant improvement of the
healing rate. Actually, it seems to only increase the costs, without any significant
impact on the patient healing.
7 Conclusions
The advantages of VAAFTare obvious. To begin with the key feature inherent to the
technique, direct vision of the operative site is of vital importance, particularly in the
management of complex perianal fistulas and recurrences. When compared with
traditional techniques, VAAFT firstly offers the advantage of minimal perianal
injuries, and secondly, it is highly effective in locating the site of the internal
opening, which is critical in perianal fistula surgery. A major aspect of the technique
is that the fistula, secondary tracts and possible abscess cavities are solel y treated
from within, therefore virtually no damage to the anal sphincter complex can be
410 P. Meinero
Operation
lime (mins) Success
disease
Crohn’s
a
(84%)
0 (0) 90 (60–120) 74%
advancement flaps
(67%)
b
(100%)
c
(73.8)
Follow-up
Age
Table 1 VAAFT success rate in literature
8.5 (6–9) Advancement flap 10 (100) 22 (18–42) 9 (81%)
(mos) Closure of internal opening
(years)
Liu et al. (2020) Germany 10 34
References Country Patients
(21–51)
India 82 35 6 Sutures or staples 0 (0) 45 (30–90) 69
Meinero and
Mori (2011)
15 (6–69) Staplers (linear or semicircular) or
5 Sutures 0 (0) 31.7 (18–45) 7 (88%)
(21–77)
(29–66)
Italy 203 42
Brazil 8 43
Schwandner
(2013)
Meinero et al.
(2014)
Poland 18 47 10 Mattress sutures/advancement flaps NR 67 (45–135) 12
Adegbola et al.
(2017)
30 NR 4 (< 1–30) NA 9 (30) NR NA
Czech
Republic
Garg and Singh
(2017)
Pakistan 40 NR 6 Sutures 0 NR 40
Kochhar et al.
10 (14–24) Mucosal advancement flap 1 (11) 38 (25–60) 6 (67)
34 (12–44) Staplers 0 (0) NS 29 (71)
9 Sutures or staples 1 (0.01) 55 (35–90) 44 (85)
(0.6–15.9)
(18–69)
(19–71)
Italy 9 9.6
Singapore 41 44
Emile et al.
China 52 48
(2018)
Seow-En et al.
(2016)
Total 917 21 (2)
(2017) 21:775–782
From S.O. Adegbola et al. “Short term efficacy and safety of three novel sphincter- sparing techniques for anal fistulae: a systematic review”. Tech. Coloproctol.
Malaysia 8 42.5 NR Sutures NR NR NR
India 416 NR NR Linear or semicircular staplers NR 50 (22–94) 99
Jiang and Liu
Walega et al.
(2014)
(2014)
Zheng et al.
(2017)
(2018)
25 VAAFT 411
caused. Accordingly, the risk of postoperative incontinence is minimal. The patient’s
quality of life is manifestly improved.
In the hands of a skilled surgeon using VAAFT, in principle, it is not requi red to
know in advance the site and course of the fistula tract(s) in relation to the external
anal sphincter as defined by the Parks classification, because the relationships
between the fistula pathway(s) and the sphincter apparatus are not visible while
operating from the inside.
What is more, there is no need for the patient to visit the clinic or ambulatory care
center for the most elementary aftercare (which can be notoriously painful after
traditional surgery). In view of the minimal surgical wounds resulting from this
approach, postoperative dressing changes and wound care, which may include
irrigations with saline solution, can be done at home. In the absence of postoperative
complications and given adequate patient compliance, resumption of normal physical activities and work is usually permissible in the third postoperative week, or
even earlier if the work is sedentary. VAAFT is commonly performed in a day
surgery setting or with an overnight admission after surgery in more complex clinical
circumstances (Meinero, 2021).
References
Adegbola SO, Sahnan K, Pellino G, Tozer PJ et al (2017) Short-term efficacy and safety of three
novel sphincter-sparing techniques for anal fistulae: a systematic review. Tech Coloproctol 21:
775–782
Adegbola SO, Sahnan K, Tozer PJ, Strouhal R, Hart AL, Lung PFC, Phillips RKS, Faiz O,
Warusavitarne J (2018) Symptom amelioration in Crohn’s perianal fistulas using video assisted
anal fistula treatment (VAAFT). J Crohn’s Colitis 12(9):1067–1072
Emile SJ, Elfeki H, Shalby M, Sakr A (2018) A systematic review and meta-analysis of the efficacy
and safety of video-assisted anal fistula treatment (VAAFT). Surg Endosc 32:2084–2093
Garg P, Singh P (2017) Video-assisted anal fistula treatment (VAAFT) in Cryptoglandular fistula-in-
ano: a systematic review and proportional meta-analysis. Int J Surg 46:85–91
Jiang HH, Liu HL et al (2017) Video assisted anal fistula treatment (VAAFT) for complex anal
fistula: a preliminary evaluation in China. Med Sci Monit 23:2065–2071
Kochhar G, Saha S et al (2014) Video-assisted anal fistula treatment. JSLS 18(3):1–5
Liu H, Tang X, Chang Y et al (2020) Comparison of surgical outcomes between viceo-assisted anal
fistula treamente and fistulotomy plus seton for complex anal fistula: a propensity score
matching analysis – retrospective chjort study. IntJSurg 75:99–104
Meinero P (2021). Video Assisted-Treatment of Anal Fistula (VAAFT) and Pilonidal Sinus Disease.
A concise report on the Meinero’s techniques. Hand to hand manual. ENDO-PRESS. Karl Storz
SE Tuttlingen-Germany. p. 11
Meinero P, Mori L (2011) Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving
procedure for treating complex anal fistulas. Tech Coloproctol 15:417–422
Meinero P, Mori L, G, Gasloli. (2014) Video-assisted anal fistula treatment: a new concept of
treating anal fistulas. Dis Colon Rectum 57:354–359
Pini Prato A, Zanaboni C, Mosconi M et al (2016) Preliminary results of video assisted anal fistula
treatment (VAAFT) in children. Tech Coloproctol 20(5):279–285
Regusci L et al (2020) Video assisted anal fistula treatment (VAAFT) for complex anorectal fistula.
Efficacy and risk factors for failure at three-year follow-up. Tech Coloproctol 24(7):741–746
412 P. Meinero
Rojanasakul A et al (2007) Total anal sphincter saving technique for fistula-in-ano: the ligation of
the intersphincteric tract. J Med Assoc Thai 90(3):581–586
Sangwan YP, Rosen L, Riether RD, Stasik JJ, Sheets JA, Khubchandani IT (1994) Is simple fistula-
in-ano simple? Dis Colon Rectum 37(9):885–889
Schwandner O (2013) Video-assisted anal fistula treatment (VAAFT) combined with advancement
flap repair in Crohn’s disease. Tech Coloproctol 17:221–225
Seow-En I, Seow-Choen F, Koh PK (2016) An experience with video-assisted anal fistula treatment
(VAAFT) with new insights into the treatment of anal fistulae. Tech Coloproctol 20(6):389–393
Tozer P, Sahnan K, Adegbola S, Shaikh S, Lung P (2019) Video-assisted anal fistula treatment
(VAAFT) assisted seton placement – a video vignette. Color Dis 21(12):1462
Walega P, Romaniszyn M, Nowak W (2014) VAAFT: a new minimally invasive method in the
diagnostic and treatment of anal fistula – initial results. Pol Prezegl Chir 86(1):7–10
Yao YB et al (2021) VAAFT plus FiLaC: a combined procedure for complex anal fistula. Tech
Coloproctol 25(8):977–979
Zelić M, Karlović D et al (2020) Video-assisted anal fistula treatment for treatment of complex
Cryptoglandular anal fistulas with 2 years follow-up period: our experience. J Lap Adv Surg
Tech 30(12):1–4
Zheng L, Lu J, Pu Y, Xing C, Zhao K (2018) Comparative study of clinical efficacy between video-
assisted anal fistula treatment and traditional fistula resection plus seton in treatment of comples
anal fistula. Zhohnghua Wei Chang Way Ke Za Zhi 21(7):793–797
The Laser Treatment of Anal Fistulas
26
Aynur Safiyeva
Contents
1 Introduction . ............... .................................................................. 414
1.1 Literature Review . ..................................................................... 414
1.2 Generalized Information on the Etiology, Pathogenesis, and Classification
of Complex Anal Fistulas ........ ..................................................... 415
1.3 Diagnosis and Treatment of Complex Anal Fistulas ................................. 420
1.4 The Current Condition in the Treatment of Complex Anal Fistulas ................. 422
2 Materials and Methods ........................... ........................................... 427
3 Conclusion ................................................................................... 429
References ............................ ............................................... ............ 429
Abstract
The chosen study aims to scrutinize the laser treatment methods in anal fistulas,
which is considered one of the novel-based operations in recent years. The anal
fistula is a pathological pathway between the perianal skin and the opening of the
rectum, mainly caused by inflammation of the tissues surrounding the rectum.
The fact that the disease is considered more common in able-bodied people,
emphasizing its social significance, makes it necessary to search for new methods
of treatment. The classification, treatment, and diagnosis of the disease have been
the subject of heated discourse and discussions up to date. The pivotal reason for
this is the high variability of complications, despite serious scientific research. In
recent years, new trends in the treatment of complex anal fistulas have been
observed in the United States and Europe, which are based on the application of
new tissues obtained using modern advances in biotechnology, including biodegradable materials, and bioprosthetic plugs made of biomaterials, and laser
treatment. In 2011, the laser was introduced in the treatment of anal fistulas
amid the 2011 pilot study. In this study, a new technique was developed using a
newly invented radial emitting laser probe (“FiLaC™,” Biolitec, Germany) to
A. Safiyeva (*)
Central Customs Hospital, Baku, Azerbaijan
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_28
413
414 A. Safiyeva
eliminate the fistula epithelium and the remaining fistula trace. The main direction
of scientific research in the surgical treatment of anal fistulas is the substantial
assessment of anal fistulas in the preoperative period, the nature and direction of
the fistula, and the location of the internal hole as well as the relationship to the
sphincter.
Keywords
Anal fistula · Laser treatment · Anal fistula · Fistula abscess · FiLAC
TM
1 Introduction
In the last few decades, due to the increase in proctologic diseases, more attention
has been paid to the diagnosis, treatment, and rehabilitation of these diseases. Thus,
the development of proctological diseases is mainly associated with an increase in
improper foods, nutrition with them, and semifinished foods. It is an undeniable fact
that colorectal diseases can be found not only in the elderly but also in young people.
In this regard, studies reveal that it affects 8.6 people per 100,000 people. Among
men, the proportion is 12.3 per 100,000 population, but it is slightly lower among
women, estimated at 5.6 per 100,000 women. Therefore, the ratio difference
between men and women is 1.8:1 (Whiteford et al. 2005). The core age group of
patients constitutes 38.3 years leading to long-term disability to work and, as a result,
disability, which is of socioeconomic importance and creates many problems for
family and sex life.
The anal fistul a is a pathological pathway between the perianal skin and the
opening of the rectum, mainly caused by inflammation of the tissues surrounding the
rectum. It is the fourth most common proctological disease right after hemorrhoids,
anal fissures, and colitis, accounting for 20–40% of rectal diseases, which is rounded
to 0.5–4% among surgical diseases. The fact that the disease is considered more
common in able-bodied people, emphasizing its social significance, makes it necessary to search for new methods of treatment. These will mainly serve both the
principles of quality treatment and the short-term rehabilitation period and, consequently, the early recovery of working capacity.
1.1 Literature Review
The classification, treatment, and diagnosis of the disease have been the subject of
heated discourse and discussions up to date. The pivotal reason for this is the high
variability of complications, despite serious scientific research. After surgical procedures, 7–30% and, in some cases, up to 64% of treatment results were considered
unsatisfactory, and recurrence of fistulas was observed in 15–30% of cases
(Emmanuel and Kamm 2000). The frequency of sexually transmitted diseases is
also assessed differently by different scientists in the literature. Some authors do
26 The Laser Treatment of Anal Fistulas 415
emphasize that there is no sex factor in this disease, and on the other hand, some
experts hold the opinion that the disease is more prevalent among women (SudolSzopinska et al. 2002a). Some n ote that this pathology occurs with the same
frequency among women and men, while others indicate that the pathology is
more common in men than in women. The historical roots of anal fi stulas as a
disease date back to ancient times. Even in his time, Hippocrates emphasized that the
treatment of fistulas was surgical. The English surgeon John Arden (1307–1390) in
his Treatises of Fistula in Ano, Hemorrhoids, and Clysters in 1376 described the
ligature method and fistulotomy. In the late nineteenth and early twentieth centuries,
scientists such as Goodsall and Miles, Milligan and Morgan, Thompson, and
Lockhart-Mummery also voiced their views on the treatment of fistulas in their
scientific research.
However, it is unfortunate that the analysis of opinions and thoughts on the
surgical treatment of anal fistulas still does not shed light on the problem (Chapple
2000). It is first necessary to clarify the type of anal fistula and its relationship to the
sphincter, for example, what level it passes through the sphincter, and how it covers
it, and give the correct anatomical classification of complex fistulas to determine the
effectiveness of the applied treatment methods (Galetti and Furardi 2000).
The result of treatment is directly proportional to the relationship of fistulas to the
sphincter. While subcutaneous fistulas are considered inter-sphincter, which result in
98% healing, surgical treatment of extra- and trans-sphincter fistulas is still relevant
as a surgical problem and has a high recurrence rate in treatment (Sultanov 1986).
The urgency of this problem is due to the search for new principles of treatment of
extra and trans-sphincter fistulas. Sometimes it is difficult to determine the effectiveness of simple and complex fistulas because surgeons usually show a total
percentage of recovery in the surgical treatment of anal fistulas. Indeed, these
summary statistics mislead surgeons and lead to false conclusions and do not reflect
the effectiveness of real treatment principles. Thus, taking into account the relationship of anal fistulas to the sphincter, the choice of surgical treatment should have to
be placed in the center of attention.
1.2 Generalized Information on the Etiology, Pathogenesis,
and Classification of Complex Anal Fistulas
The main direction of scientific research in the surgical treatment of anal fistulas is
the substantial assessment of anal fistulas in the preoperative period, the nature and
direction of the fistula, and the location of the internal hole as well as the relationship
to the sphincter. The clarification of these features is directly proportional to the type
and technique of the operation and the results obtained in the postoperative period.
For the correct diagnosis and treatment of anal fistulas, it is necessary to know and
evaluate the anatomy of the anal region. The anal canal is cylindrical and is
surrounded by two muscular sphincters, divided into external and internal. The
external sphincter is adjacent to the anoxic part at the back and the urogenital
diaphragm at the front. The edges are surrounded by puborectal muscle. The internal