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416 A. Safiyeva
sphincter is the distal terminal part of the intestinal circulatory muscles. The longitudinal muscle of the rectum integrates into the area between the inner and outer
sphincters assuming that they are to form the anus together. The area between the
sphincters is the surgical space between the outer and inner sphincters, covers the
space between the outer sphincter and the longitudinal muscle, and is rich with
adipose tissue, formerly known as the ischioanal cavity, but, in recent years it has
been called as the ischiorectal cavity.
The reason for this change in terminology is that this area is more associated with
the anal region than the rectum. The proximal part of the anal canal is surrounded by
longitudinal muscles, called the Morgan anal column. In the distal part, each column
joins the adjacent column with small crescent areas (anal glands) to form the small
pockets. These are Morgan crypts, which are also replaced by a toothed line, and
called the histological transit zone between the anal epithelium and the rectal
epithelium.
Anal fistulas are a complication of acute paraproctitis mainly characterized by the
presence of an internal hole in the intestine, the fistula tract, and an external hole in
the perianal area (Alemdaroghlu and Bugra 2004). Simultaneously, the presence of
concomitant diseases in patients also contributes to the spread of this disease by
promoting the presence of abscesses in the anal region. Thus, people with diabetes,
Crohn’s disease, previous surgeries on the perianal area, and HIV (human immunodeficiency virus) are more likely to develop the disease. The main factor here is the
insufficient drainage of abscess cavities in the area.
It should be noted that 96% of anal fistulas are caused by an anal abscess.
However, the anal fistula sometimes develops right after anal fissures, hemorrhoids,
proctitis, proctosigmoiditis, cryptitis, polyps of the rectum, and other anorectal
diseases. Therefore, the fundamental role in the etiology of the abscess is the
penetration of the infection into the anal tissue, which is due to the anatomical
structure of the region, and the anatomical regions where it is located are in this
order: 42% of perianal region, 20% of the ischiorectal region, supra-levator region
7% (Karu 1997).
The infection of the anal glands forms an abscess cavity in the inter-sphincter
area. If the infection spreads downwards, it causes a perianal abscess. The pus
spreading from the puborectal region to the external sphincter may also cover the
ischiorectal cavity. This pus not only spreads even to the postanal distance, covering
the opposite ischiorectal space, but also promotes the formation of irregular pus and
as a result, an irregular fistula (Luck and Hewet 1999). The abscess in the intersphincteric region progressing upwards results in the formatio n of a supra-levator
abscess. The infection can be transmitted hematogenously and lymphogenically
from the anal glands, the damaged mucous membrane of the rectum, as well as the
neighboring organs damaged by the inflammatory process.
Most researchers do believe that the most common route of infection is through
the anal glands, which are located in the intermuscular area of the rectum and open to
the Morgan crypts. Up to 6–8 glands are opened in each anal crypt. Large and deep
crypts (Morgan) are more prone to suppurate and are considered a gateway for
infections. It develops as a result of obstruction of the ducts that connect the anal
26 The Laser Treatment of Anal Fistulas 417
glands with the anal glands. At the same time, the evacuation of secretions into the
intestinal tract stops or is delayed. As a resul t of intestinal infection, it becomes
inflamed and develops an anal abscess.
The abscess cavity opens spontaneously or surgically to the skin of the perianal
area and adjacent areas (ischiorectal, pelvirectal, and retrorectal areas). The frequent
or periodic infection of the anal tissues, the degree of drainage of the pus, and
sometimes, the opening of the pus in several places on the skin leads to the transition
of the rectum to an anal fistula, mainly characterized by the presence of internal and
external holes (Loungnarath et al. 2004).
Anal fistulas of specific origin, such as tuberculosis, syphilis, and actinomycosis,
can also be found. Fistulas with tuberculosis etiology are rounded to about 5%.
Venereal diseases can also cause fistulas in the anorectal region. In diseases including syphilis, lymphogranulomatosis, and HIV, the perianal abscess may occur, which
may be aggravated by anal fistula.
During anal fissures, there is a violation of the integrity of the mucosa in the
posterior wall, due to damage to the areas of the fecal mass with poor blood supply. It
creates a fertile ground for infections, leading to the development of paraproctitis,
which in turn aggravates the fistula. Transformation of anal lymphadenitis into anal
fistula can also be found in the literature.
The surgical treatment should be considered in patients with Crohn’s disease
etiology. Thus, in addition to the surgical treatment of fistulas, their therapy should
be carried out. The studies reveal out a positive trend in the use of infliximab,
monoclonal antibody TNF (tumor necrosis factor) in the drug treatment of this
disease. Proctocolectomy is indicated in the surgical treatment of recurrent anal
fistulas of Crohn’s etiology (Ozunek et al. 1996).
In some studies, the anatomical examination of the anal sphincter was performed.
It was determined that the length of the subcutaneous portion of the sphincter muscle
is 0.3–0.75 cm, width 0.3–1.0 cm; length of the superficial position 0.8–1.5 cm,
width 0.5–1.5 cm; and length of the deep position 0.4–1.0 cm, width 0.5–1.0 cm.
Unfortunately, the volume of the anal sphin cter cannot be characterized based on the
physically quantitative indicators, which does not help to clarify the extent of
sphincter muscle rupture in patients with trans-sphincter fistula during surgery
(Schouter et al. 1999).
Thus, one of the characteristic anatomical features of trans-sphincter fistulas is
that the fistula passes through different levels of anal compression. The extent of
the surgery and the compression rupture mainly depend on the level of penetration of
the anal sphincter muscle of the fistula. The most commendable types of surgery in
the surgical treatment of anal fistulas are those that do not damage the anatom ical
structure of the perianal region (Sentovich 2003).
Several types of classifications have been developed mainly based on anatomical,
etiological, and radiological factors. According to the current classification, the
complex fistulas are divided into two types: trans-sphincter and extra-sphincter.
The success of the treatment of anal fistulas depends on the correct identification
of its clinical forms and the choice of appropriate treatment principles. In this regard,
they are classified according to the nature of the perpetrators as follows:
418 A. Safiyeva
1. Anaerobic etiology
2. Aerobic etiology
3. Etiology of tuberculosis
4. Actinomycosis origin
For the classification of fistulas, the activity index of perianal diseases should be
clarified, divided into five main categories:
1. Presence of secretions from the perianal region
2. Patients complain of pain
3. Decreased sexual activity during the disease
4. Type of perianal disease
5. Induction rate
Under the Parks classification, there are the following types of fistulas:
1. A (superficial) fistula – located below the external and internal sphincters.
2. B (intra-sphincter) is between the fistula-external and internal sphincter.
3. C (trans-sphincter) covers the inter-sphincter area by passing through the fistula-
external anal sphincter.
4. E (extra-sphincter) penetrates the levator outside the fistula-external anal
sphincter.
The following are forms according to the etiological factor:
1. Non-specific (banal)
2. Specific
3. Posttraumatic
There are other reasons for the development of complicated anal fistulas:
1. Diverticulitis
2. Fistulas after radiation treatment of prostate and rectal cancer
3. Anal fistulas of tuberculosis origin
4. Fistulas formed after steroid therapy
5. Anal fistulas against the background of HIV infection
6. Fistulas of actinomycosis origin
7. Chlamydial fistulas
Paul Belliveau gave another classification of anal fistulas that suggests that the
choice of types of surgery should be based on the anatomical structure:
1. Inter-sphincter
2. Trans-sphincter
3. Down
26 The Laser Treatment of Anal Fistulas 419
4. Top (up)
5. Supra-sphincteric
6. Extra-sphincteric (Fathmann 1997)
7. Irregular
1. The intra-sphincteric anal fistulas are considered subcutaneous or sublingual
and account for 70% of anal fistulas. In patients with this fistula, the external hole of
the fistula is identi fied, and it is located at a distance of 1–3 cm from the anal hole in
almost all patients. In 95% of cases, an external hole is marked in the intra-sphincter
fistula, and the resulting fistula is mostly straight. Palpation of the fistula can also
reveal sublingual and subcutaneous areas. Methylene test and metal probe are used
in the diagno sis of intra-sphincter fistulas. The probe inserted through the external
foramen enters the rectum or sublingual region very freely through the internal
foramen and allows the fistula tract to be detected very easily. The number of
complications and relapses during surgery for these fistulas is considered minimal.
The function of the sphincter of the rectum is not impaired, as the fistula passes
through the intra-sphincter, and the process of scarring in the anal canal is practically
nonexistent.
2. Trans-sphincter anal fistulas occur in 25% of cases. Its characteristic feature is
that the fistula passes through the sphincter. Transfunctional anal fistula occurs
spontaneously as a result of ischiorectal paraproctitis or non-radical opening of
pus. Trans-sphincter fistulas sometimes lead to the development of inflammatory
processes such as proctitis and proctosigmoiditis. One external hole is noted in 50%
of cases, two external holes in 45% of cases, and three external holes in 3% of cases.
The probe inserted through the external foramen goes in the direction of the rectum
and passes freely in 60% of patients from the orifice into the internal foramen or
subcutaneous layer.
3. Extra-sphincter anal fistulas mainly occur in 1% of cases. They are considered
to be complicated fistulas and are the result of acute ischiorectal, retrorectal, and
pelvirectal paraproctitis, characterized by a branched fistula, scarring in the wall of
the anal canal, and the spread of the purulent process to the area around the anal
tissue. Patients often complain of pus leaking from the external hole. Patients show
signs of general and local intoxication, and the symptoms worsen up to 5–7 times.
The external foramen is 5–7 cm outside the anus, sometimes close to it. Extrasphincter fistulas have 2–4 external openings, rarely one external hole or more than
4. Palpation does not touch the fistula, but scarring is noted. Finger examination
allows the detection of an internal hole, which in many cases, is in the form of a
funnel. The probe inserted through the external hole runs parallel to the anal canal,
which explains the nature of the extra-sphincter fistula. Unlike other anal fistulas,
this type of fistula rarely enters the rectum. The fistula path is branched in the
fistulogram, and the sphincterometry readings are slightly lower.
4. The incomplete internal fistula of the rectum is identified by the presence of a
fistula hole in the opening of the rectum, which accounts for 8–10% of all
fistulas.
These fistulas result from the opening of an abscess through an internal hole in the
damaged anal canal in the rectum. As a result, it is observed that both holes are in the
420 A. Safiyeva
opening of the intestine. Clinically, intermittent maceration, pain in the perianal area
on palpation, and infiltrating in the anal tissue are found in these patients. During the
manual inspection, the internal hole is marked on the back crypt in 85% of cases.
Probe examination is less informative. The results of sphincterometry are usually
higher than normal due to the sphincter spasm. The prolonged pectenosis sometimes
causes the narrowing of the anal canal.
5. Horseshoe fistula branches from the rectum to the right and left. This form of
the fistula is the involvement of anal tissues of the same name and sometimes
different cells in the inflammatory process on both sides of the rectum. They
constitute 4–10% of total fistulas and vary depending on the relationship of the
fistula to the sphincter. Thus, 12% of patients have an intra-sphincter, 31% have a
trans-sphincter, 43% have an extra-sphincter, and 14% have a combined form. There
are two external openings, one to the right and one to the left of the anus. During the
probe examination, the probe either passes through the opening of the rectum or is
close to it. Amid the manual investigation, scar tissue is found in the anal canal and
the internal hole (118).
1.3 Diagnosis and Treatment of Complex Anal Fistulas
Treatment of patients with complicated anal fistula is directly proportional to its
diagnosis. Proper diagnosis allows you to choose the most effective treatment. In this
regard, it is crucial to study the localization of the internal orifice, the relationship of
pus, the fistula tract, and its branches to the sphincter, as well as the functional state
of the anal opening valve (Moskowitz et al. 2003). Intra and trans-sphincter fistulas
do not engender any difficulties during the diagnosis.
However, both in the preoperative period and amid surgery, it is not possible to
learn the course of the fistula and its branches, its relationship to the sphincter
muscle, the localization of the internal hole and the development of scarring
around it, the presence of purulent cavities around the rectum, their topical
localization, functional status of the anal sphincter, and other necessary issues.
There are no specific laboratory tests for anal fistulas. Clinical examination of the
anal fistula is carried based on the manual and radiological examination methods
(Navarro 1998).
Initially, a clinical investigation should be performed, which reveals the presen ce
of free purulent secretions in this perianal area, the external hole, the discharge of
secretions from the external hole without pressure, and skin maceration (Fathm ann
1997). Manual examination of the anal canal allows you to determine the tone of the
sphincter muscle and the location of the internal hole. The direction of the fi stula
path, whether branched or unbranched, and its relation to the sphincter muscle can be
clarified with a button metal probe. The location of the inner hole is determined by
implementing the dye injection into the outer hole.
The detailed information about the pathological process is not available based on
clinical trials alone. To acquire complete information regarding the changes in the
inflammatory process, the anatomical features of the fistula, and the internal hole, it
26 The Laser Treatment of Anal Fistulas 421
is advisable to use fistulography, which has been an indispensable diagnostic method
since the last century (Saranovic et al. 2007).
Radiologists have proposed the use of fistulography, which could help with
surgical treatment and could detect anatomical abnormalities. For more in-depth
information during fistulography, the contrast agent should be present in full in the
fistula and purulent cavities, and should not return during the investigation.
Fistulography also helps make a diagnosis by completing clinical examinations.
This examination does not produce a direct image of the sphincter muscles,
which means that any image canno t be properly visualized. In this case, it is
arduous to say the supra and infralevator localization of the fistula path
(Karpukhin and Sauresshkina 2008). The same can be said about the internal
hole of the fistula. It is due that fistulography sometimes cannot give a correct
interpretation of the location of the internal hole that leads to false deci sions and
treatment. The sclerotic changes in the wall of the fistula canal and surrounding
tissues on the background of inflammation and the development of myelofibrosis
lead to dysfunction of the anal sp hincter (Lunnis et al. 1994). According to some
researchers, the results of the operation are satisfactory in patients with functional
changes in the anal sphincter before surgery, which makes it necessary to study
the status of the anal sphincter before surgery by sphincterome try (Moskowitz
et al. 2003).
Endoanal USM has been used in coloproctology since the last century originally
proposed by Clive Bartram (Sudol-Szopinska et al. 2002b). The advantage of this
examination over other methods is that it is easy to perform, which is completely
noninvasive, harmless, simple, and short-lived. During this procedure, the patient
lies in the left lateral position, and the inner sphincter is described as a hypoechogenic ring and the outer sphincter as a mixed exogenous form (Poen and FeltBersma 1998). The endoanal USM examines the muscle fibers of the inner and outer
sphincter more accurately. According to other authors, this examination is of great
importance in cases of anal incontinence (Maier et al. 2001).
This examination accurately assesses the degree of damage to the internal and
external sphincter muscles, degenerative changes of the internal sphincter, and
atrophy of the sphincter muscles. According to some authors, USM data can be
corrected by anal manometry and electromyography during anal incontinence. The
endoanal USM correctly identifies the internal hole and can accurately describe its
images, even if there is a purulent accumulation in the surrounding tissues (Lengley
et al. 2002). Currently, USM is distinguished by its high informativeness in the
assessment of sphincter function.
In recent years, the highly informative MRI can be considered the diagno stic tool
of choice. Regarding providing the correct classification of the fistula path, MRI also
promotes the effective direction of its surgical treatment (Lurin et al. 2008). The
advantages of MRI over other investigation methods are:
1. MRI is indispensable not only in the diagnosis of anal fistulas but also in recurrent
ones. The MRI image provides a precise localization of this process, which
contributes to the correct surgical examination.
422 A. Safiyeva
2. The success of MRI is that it penetrates the tissues at a high level and can provide
an accurate classification of fistulas, which directly affects the quality of treat-
ment. As a result, postoperative recurrence is reduced by 75% of fistulas
(Schratter Sehn et al. 1993).
MRI has been used in the diagnosis of anal fistulas for the last 5 years. This
method of the examination allows surgeons to identify pathologies that can be
diagnosed on time by giving the correct classification.
1.4 The Current Condition in the Treatment of Complex Anal
Fistulas
Modern treatment of complex anal fistulas is surgical. Various methods are used to
eliminate this pathology, which is not always successful (Sultanov 1986a). Recently,
scientists have considered conservative attempts unsuccessful in the treatment of
complex anal fistulas and are working towards a scientific search for modifications
of new surgical methods. The reason why this idea is always dominant can be
interpreted as follows: the postoperative consequences of complicated anal fistulas
are not always satisfactory. It is due that sphincter damage sometimes occurs during
surgery, which in turn, causes sphincter insufficiency, and its correction is more
complicated than the removal of the fistula itself (Mc Ardle et al. 1995). The clinical
and topographical-anatomical diver sity of anal fistulas and the high frequency of
adverse outcomes of surgical treatment have led to the development of various
modifications of surgical operations and their application in practice (Tocchi
1997). The main principle in surgical treatment is the elimination of the internal
hole, complete removal of the fistula and its branches, opening of purulent cavities,
and adequate drainage of the cavity. Recently, many authors consider the use of
ligature in the surgical treatment of trans-sphincter and extra-sphincter fistulas.
Several foreign sources state that varied functional results are acquired after ligature
removal of the fistula. Thus, Willams et al. (1995) performed ligature + fistulotomy
in 24 patients and received only 8% recurrence. Lunnis used this method in 1994 in
37 patients and received a 7% recurrence. Van Tets and Kuipers applied this method
to 267 patients in 1994 and obtained only 10% recurrence (Palmer et al. 2002). The
basis of the mechanism of this method is the form ation of granulation tissue in the
connective tissue in the fibrous tissue. As a method, it has some superior features:
1. The number of relapses is relatively low.
2. It is used in the treatment of fistulas of a very complex category.
3. It is technically easy to implement.
However, there are some short comings:
1. Long-term treatment and prolongation of hospital stay
2. Probability of anal sphincter insufficiency in the postoperative period
26 The Laser Treatment of Anal Fistulas 423
Other methods of treating anal fistulas include fistulectomy and mucosal resection. Fistuloectomy is performed based on the following principles:
1. Detection of fistula pathway
2. Secondary dilatation of the fistula tract
3. Adequate drainage and removal of pus
4. Removal of the fistula
It is of scientific interest to perform the method of lowering the mucous membrane to eliminate the internal hole, the gate of infection. For the first time, this
method was developed in 1912, and the operation was based on the Whitehead
operation. In 1948, D.R. Laird performed several successful operations with this
method.
Another modification of this method is the Djad-Robl e operation: the mucous
membrane is peeled “P”-shaped, lowered to the inner hole, and thus the inner hole is
closed (Navarro-Luna et al. 2004). Parks recommends that the intra-sphincter portion of the fistula be eliminated along with the surrounding anal glands and crypts,
which may be infected (Loungnarath et al. 2004).
P. Belliveau notes sphincter insufficiency after fistulectomy with external sphincter protection. It once again proves the essential role of the sphincter muscle in the
pathogenesis of anal sphincter insufficiency and the need for its protection during
surgery (Bonatti et al. 2004).
Closure of the internal hole of complex fistulas with flap can sometimes lead to
the formation of local inflammation and necrosis of the plastic flap against the
background of a purulent wound after plastic surgery (Grakov et al. 2000). Hence,
the preparation of patients before and after surgery and the use of topical and oral
antibiotics are noted. Ortiz and Marzo (2000) emphasize the use of antibiotics only
for prophylactic purposes, Zimmerman et al. (2003) emphasizes the use of antibiotics for 3–5 days after surgery, and Sonoda (2002) considers it advisable to send the
patient home with oral antibiotics (Zimmerman et al. 2001). In recent years, Paul
Belliveau has developed an algorithm for the treatment of anal fistulas.
1. Abscess drainage – secretion from the abscess cavity
2. Suspicion of anal fistula – detection and type of fistula
3. Treatment: a different approach in simple and complex fistulas
4. In simple forms: complete open fistulotomy and improvement
5. In complex form:
(a) Application and advancement of ligature method
(b) Endoanal plasticity and improvement
(c) Fecal incontinence in combination with plastic surgery or fistulotomy
(Fathmann 1997
)
In recent years, various scientists have analyzed the methods in the treatment of
anal fistulas for recurrence of anal fistulas and the degree of anal sphincter insufficiency and obtained the follow ing results. When the same method was conducted by
424 A. Safiyeva
Garcia Olmo, Vazquez Aragorn, and Lopez Fando in 12 patients, no recurrence was
revealed, and ACE was observed in 33% of cases. According to Dziki and Bartos,
the ligature method is a treatment that significantly reduces the likelihood of
recurrence. Placencia Hardy (1985), Hyman (1999), and Schouten, and Zimmerman
(1999) performed plastic surgery on the mucous membrane to close the inner hole
during anal fistula treatment. While Plasencia received only a 2% recurrence in
151 patients using this method, Hyman experienced this relapse in 19% of
33 patients. In Zimmerman’s experience, these figures were almost the same, and
relapses were observed in 25% of 44 patients (Zimmerman et al. 2003).
Since the beginning of the twenty-first century, there has been an increasing trend
in the treatment of anal fistulas to be less traumatic, shorter inpatient periods, and
preference to surgical procedures that serve early recovery of working capacity. In
recent years, new trends in the treatment of complex anal fistulas have been observed
in the United States and Europe. These trends are based on the application of new
tissues obtained using modern advances in biotechnology, including biodegradable
materials and bioprosthetic plugs made of biomaterials.
Their use is due to their low invasiveness and the absence of complications such
as anal sphincter insufficiency in the postoperative period. The use of these materials
is to serve the self-regeneration of tissues by closing the outer and inner holes. For
this purpose, various gels or substances made from animal tissues are injected into
the fistula and allow the fistula to heal on its own inside the canal (Meissner 1996).
Later, acellular dermal matrix and Gore Bio-A fistula plugs were used, and the
study reported a 40–80% recurrence (Williams et al. 1995). Based on a comprehensive analysis of the unsatisfactory results, the causes of postoperative complications
and relapses can be interpreted in this way.
1. Preoperative errors: incorrect identification of the fistula and the presence of
unexamined branches and purulent cavities
2. Technical defects and technical difficulties during the operation: false identifica-
tion of the internal hole, neglect of purulent cavities, and incomplete operation
quality as a result of technical barriers
3. Defects in postoperative treatment: the formation of large scars on the wound as a
result of long- term treatment and false fistulas as a result of early wound healing
(Sultanov, 1986b)
4. Improper etiotropic therapy in the treatment of complex anal fistulas of specific
etiology
The idea of approbation in the clinical practice of sphincter-protective treatment
in complex anal fistulas also arises from this. Special attention was also given to the
possibility of unification of the operation, which can be performed on a large scale by
surgeons of general profile.
The application of TFG gel without touching the sphincter muscles is also aimed
at improving the positive results of the treatment of complex anal fi stulas. The
research was carried out at the Department of Surgical Diseases I of the
Azerbaijan Medical University. Thus, TFG was applied to 81 patients and deeply
26 The Laser Treatment of Anal Fistulas 425
analyzed. In our results, the use of TFG gel in the treatment of complex anal fistulas
reduced the freque ncy of postoperative complications from 40.0 7.7% to
24.4 6.7%. In other words, according to our results, the chances of complications
listed in the core group were two times less than in the control group: estimated at
SHN - 0.48 (0.19–1.25). Therefore, the use of TFG in the treatment of complex anal
fistulas is reflected in the clinical trials, which are characterized by less traumatic
operation, lower incidence of complications in the postoperative period, and shorter
inpatient duration (Safiyeva 2012).
In 2011, the laser was introduced in the treatment of anal fistulas amid the 2011
pilot study introduced by Wilhelm (Nikitin and Volkov 1996). In this pilot study, a
new technique was developed using a newly invented radial emitting laser probe
(“FiLaC™,” Biolitec, Germany) to eliminate the fistula epithelium and the
remaining fistula trace. During the pilot study, 11 patients with cryptoglandular
anal fistula were operated on, and all patients underwent previous surgery up to
6 times before the final surgery. In the primary operation, the first abscess was
drained, the internal opening of the fistula was determined, and a seton drain was
placed. During fistula repair, the flap technique was used to close the internal
opening normally. The remaining fistula mark was mechanically cleaned out, the
laser was inserted into the track, and energy was applied homogeneously at a
wavelength of 1450 nm and 13 watts.
While allowing the probe to retract continuously, the remaining epithelium was
eliminated, and the fistula scar was removed. The median follow-up was 7.4 months.
Nine out of 11 tubers showed initial healing (81.8%). Only a small form of the
seizure (li mited contamination) was detected, and no complications occurred. In
addition to conventional surgery, the use of a new diode laser source and a radial
probe laser probe is a very cutting-edge technique in the repair of sphincter protective anal fistula. The observed healing rate is high. There are good short-term
functional outcomes without procedure-related complications due to minimized
sphincter muscle trauma.
The procedure also involves closing the internal opening through the anorectal
flap. When some wound tissue prevents this, either a mucosal or anodermal flap is
used to close the internal opening. In the pilot study, 11 patients with cryptoglandular
fistulas underwent a FiLaC™ procedure with a total success rate of 81% in
4–7 months of clinical follow-up.
This new sphincter-saving technique uses an emitting laser probe (Fistula Laser
Closure (FiLaC™), Biolitec, Germany), which destroys the fistula epithelium and, at
the same time, annihilates the remaining fistula tract. Since the crucial cause of
surgical failure is the remnants of a persistent fistula tract or nonremovable fistula
epithelium, the newly developed radial radiating laser probe is said to circulate the
fistula epithelium or any granulation tissue in a circular motion and then destroy the
fistula tract with a shrinkage effect.
Simple diathermy cannot provide a shrinking effect on the tissues, and it becomes
more challenging to regulate the potential heat damage to the sphincter muscles. The
modi
fied laser procedure was adopted by Giamundo et al. which consists of laser
sealing of the fistula tract without the need for an endoanal flap (Orlova et al. 2007).