Video-assisted Anal Fistula Treatment Research Articles

Minimally Invasive Anal Fistula Treatment—a True Minimal Invasive Surgical Procedure

A surgical procedure comprises of two aspects—the surgical access and surgery on the target organ. For decades, general surgeons focussed their minds to propel development in the latter, i.e., surgery on the target organ. Trauma due to surgical access was considered inevitable. Patient discomfort, debility, and disfigurement were considered to be a small price the patients were paying in the larger interest of surgical cure. The advent of minimal access surgery revolutionized the concept of surgical practice. The approach placed the patient at the center of all surgical decisions. It was for the first time that the comfort and needs of the patient were given paramount importance. Through minimal access surgery, the trauma of surgical access has been dramatically minimized, with shorter hospital stay and greater patient satisfaction. Today, minimal access surgery is firmly established in the armamentarium of surgeons worldwide. The early postoperative sequelae following management of anal fistulae in terms of postoperative pain, need for dressings, and time taken off work has not been reported much in literature. Mostly, long-term outcomes in terms of recurrence and incontinence have been addressed in studies reported so far. Traditional techniques including fistulectomy and use of cutting seton have been associated with incontinence, especially in patients who have had previous surgery. Mucosal advancement flaps are technically challenging and are associated with high recurrence rates and high rates of incontinence postoperatively. Although surgical field has undergone significant evolution over the past few decades, the surgical management of the perianal anomalies is yet to witness a technological breakthrough. Apart from treatment of hemorrhoids, there have not been many surgical innovations for perianal infective pathologies. The newer treatment options include use of fibrin glue, bio-prosthetic plugs, and ligation of intersphincteric fistula tract (LIFT) and video-assisted anal fistula treatment (VAAFT). LIFT procedure has been associated with good healing rates. The early results with the use of VAAFT have been encouraging so far. The video-assisted anal fistula treatment (VAAFT) was developed by Professor P. Meinero in 2006 [1]. However, we strongly feel and advocate the terminology of minimally invasive anal fistula treatment (MAFT), which is much more appropriate and is the correct description of the procedure. MAFT qualifies as a trueminimal invasive surgical procedure. There are no iatrogenic incisions for access on the patient. Surgical access is obtained from a pre-existing pathological opening of the fistula. The technique comprises identification and secure internal closure of the internal fistula opening and visualization with cauterization of the fistulous tract using a specially designed fistuloscope. The MAFT is based on the same principles as other procedures for closing the internal opening and obliterating the tract with the innovation that allows 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 track. In our opinion, the adoption of fistuloscope-aided exploration along with effective closure of the internal opening and reinforcing the closure of the opening from the inner side of the staple/suture line is the most effective way of achieving a high healing rate for complex anal fistulas with preservation of the anal sphincter. We adopted the MAFT technique in April 2011 in an effort to reduce early postoperative morbidity and offer patients * P. K. Chowbey pradeepchowbey@gmail.com

PTU-234 Pilot study of video assisted anal fistula treatment in a district general hospital

<h3>Introduction</h3> Video-assisted anal fistula treatment (VAAFT) is a minimally invasive, sphincter-preserving procedure with low morbidity. It was the aim of this prospective study to analyse both the feasibility and preliminary results of video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair for anal fistula. <h3>Method</h3> The procedure involves diagnostic fistuloscopy and visualisation of the internal opening, followed by fulguration of the fistulous tract and closure of the internal opening with suture ligation. The video equipment (Karl Storz, Tuttlingen, Germany) was connected to an illuminating source. <h3>Results</h3> The study was conducted from October 2014 to February 2015. Twelve patients with transsphincteric fistula were operated on with VAAFT and were followed up according to the study protocol. No major complications occurred. In most cases, both short-term and long-term postoperative pain was acceptable. Primary healing was achieved in 9/9 (100%) within 3 months of the operation. The other 3 patients are still awaiting follow up. <h3>Conclusion</h3> VAAFT is a minimally invasive procedure performed under direct visualisation. It enables visualisation of the internal opening and secondary branches or abscess cavities. It is a sphincter-saving procedure and offers many advantages to patients. Our initial results with the procedure are quite promising. <h3>Disclosure of interest</h3> None Declared.

PTU-211 Novel techniques in the treatment of cryptoglandular fistula in ano: a systematic review

<h3>Introduction</h3> Fistula in ano represents a complex disease process that can be particularly challenging to treat. Several newer techniques have been developed with the intention of achieving high success rates and minimising damage to the anal sphincter complex. The aim of this systematic review was to review the published literature for novel treatment strategies and assess its effectiveness. <h3>Method</h3> A systematic review of all English language literature relevant to novel treatment strategies for cryptoglandular fistula in ano, published between 1 January 2007 and 31 Dec 2014 was carried out using MEDLINE, EMBASE and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Relevant articles were identified, quality assessed using the MINORS criteria and the data were extracted by two researchers independently. The identified novel techniques were assessed with regards to the surgical procedure, fistula healing rate, length of follow up and complication rates. <h3>Results</h3> A total of 70 potential articles were identified from the literature search. Using the predefined inclusion and exclusion criteria, 21 articles were included for the final analysis, data extraction and data synthesis. Apart from two RCT, all were retrospective or prospective case series. The identified studies reported the use of novel biomaterials (adipose derived stem cells, platelet rich plasma, Human acellular dermal matrix (ADM), Permacol™ solid implant/suspension, Acellular Dermal Matrix (ADM), Acellular Extracellular Matrix (AEM), Energy devices (Fistula laser closure-FiLaC), new types of seton sutures (Comfort Drain and self-locking cable tie), Hybrid techniques (BioLIFT, LIFT-Plug and Permacol injection-advancement flap), OTSC^TMProctology clip system and Video assisted anal fistula treatment (VAAFT). The success rates of the various techniques ranged from 37.3% to 100% over a follow up period ranging from 4–81 months without any major disturbance to continence. <h3>Conclusion</h3> This systematic review has demonstrated that there have been some pioneering technological advances to treat complex cryptoglandular fistula in ano however most of these are in an early stage of evolution. Due to the significant variation in the methodology, study design, outcome reporting of the included studies, it is not possible to meaningfully compare and contrast the described novel techniques. As with most new procedures, the early promising and enthusiastic results are often difficult to reproduce. Longer follow up data is not currently available. <h3>Disclosure of interest</h3> None Declared.

VAAFT: Video Assisted Anal Fistula Treatment; Bringing revolution in Fistula treatment.

Objective:To share our findings that the new treatment modality Video Assisted Anal Fistula Treatment (VAAFT) is a better alternate to the conventional treatments of Fistula in Ano in our setup with minor changes in the initial method described by Meinero.Methods:Karl Storz Video equipment including Meinero Fistuloscope was used. Key steps are visualization of the fistula tract, correct localization of the internal fistula opening under direct vision and endoscopic treatment of the fistula. This is followed by an operative phase of fulguration of the fistula tract using glycine solution mixed with manitol, curetting the tract with curette and fistula brush. Internal opening is closed with a Vicryl 1 suture.Result:Total of 40 patients were operated using VAAFT from October 2013 to March 2014. Three were re-operated. The other 37 cases were followed up at 6 weeks, 3 months and 6 months. Primary healing took place in 20 (50%) cases at 6 weeks. In the remaining 17 (42.5%) cases, minor discharge occurred with itching which resolved till the next visit at 8 weeks and 12 weeks.Conclusion:As the main aim in treating fistula is proper identification of the internal opening, excision of the tract and sparing the sphincter function, VAAFT achieves all aims with additional benefits of patients’ satisfaction and negligible scaring.

Modern management of anal fistula.

Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.

Video-Assisted Anal Fistula Treatment

The surgical treatment of complex anal fistulas is very challenging because of the incidence of incontinence and recurrence after traditional approaches. Video-assisted anal fistula treatment is a novel endoscopic sphincter-saving technique. The aim of this article is to evaluate the results of treating complex anal fistulas from the inside and to focus on the rationale and the advantages of this innovative approach. This is a retrospective observational study. The study was conducted at a tertiary care public hospital in Italy. From February 2006 to February 2012, video-assisted anal fistula treatment was performed on 203 patients (124 men and 79 women; median age, 42 years; range, 21-77 years) who had complex anal fistulas. One hundred forty-nine had undergone previous anal fistula surgery. Video-assisted anal fistula treatment has 2 phases: diagnostic and operative. The fistuloscope is introduced through the external opening to identify the main tract, possible secondary tracts or abscess cavities, and the internal opening. With the use of an electrode, the fistula and its branches are destroyed under direct vision and cleaned. The internal opening is closed by a stapler or a flap. Half a milliliter of synthetic cyanoacrylate is used for suture reinforcement. Successful healing of the fistula was assessed with clinical evaluation. Continence was evaluated by using patient self-reports of the presence/absence of postdefecation soiling. Follow-up was at 2, 4, 6, 12, and 24 months. The 6-month cumulative probability of freedom from fistula estimated according to a Kaplan-Meier analysis is 70% (95%CI, 64%-76%). No major complications occurred. No patients reported a reduction in their postoperative continence score. The limitations of this study included potential single-institution bias, lack of anorectal manometry, and potential selection bias. Video-assisted anal fistula treatment is effective and safe for the treatment of fistula-in-ano.

VAAFT: a new minimally invasive method in the diagnostics and treatment of anal fistulas – initial results

The aim of the study was to present our own experience in the treatment of anal fistulas by means of VAAFT (Video-Assisted Anal Fistula Treatment). Twenty patients were qualified for the VAAFT procedure. All were subjected to diagnostics. Two patients after the diagnostic stage underwent classical fistula surgery. The remaining 18 patients were subjected to the full procedure (diagnostic fistuloscopy, supply of the internal ostium, and coagulation of the fistula canal). The mean observation period was 10 months. In most cases the trans-sphincter fistula was observed during the diagnostic phase, including three with additional fluid compartments. There was one intersphincteric fistula. Considering the 18 patients subjected to the full VAAFT procedure the internal ostium was supplied by means of an advancement flap in 3 cases, while in 11 by means of a mattress suture, including one with additional tissue glue. In 4 cases the internal ostium was tightly covered by mucosa. Surgical complications were not observed during the procedure. During further observation a permanent fistula was observed in 4 (22%) patients, and in two (17%), recurrence of anal fistula. In the remaining 12 patients one observed healing without fistula recurrence. Complications were not observed, including stool and gas control deterioration (based on the FISI scoring). The VAAFT method does not affect sphincter efficiency, no intra- and postoperative complications were observed. As compared to other minimally invasive procedures a comparable recovery rate is observed without the risk of incontinence. It is the only method enabling the intraoperative identification of the internal ostium and fistula canal under visual control. Initial optimistic results require further investigations on a larger group of patients.

Video-assisted anal fistula treatment.

Background and Objectives:Fistula in ano is a common disease seen in the surgical outpatient department. Many procedures are advocated for the treatment of fistula in ano. However, none of the procedures is considered the gold standard. The latest addition to the list of treatment options is video-assisted anal fistula treatment (VAAFT). It is a minimally invasive, sphincter-saving procedure with low morbidity. The aim of our study was to compare the results with a premier study done previously.Methods:The procedure involves diagnostic fistuloscopy and visualization of the internal opening, followed by fulguration of the fistulous tract and closure of the internal opening with a stapling device or suture ligation. The video equipment (Karl Storz, Tuttlingen, Germany) was connected to an illuminating source.Results:The study was conducted from July 2010 to March 2014. Eighty-two patients with fistula in ano were operated on with VAAFT and were followed up according to the study protocol. The recurrence rate was 15.85%, with recurrences developing in 13 cases. Postoperative pain and discomfort were minimal.Conclusion:VAAFT is a minimally invasive procedure performed under direct visualization. It enables visualization of the internal opening and secondary branches or abscess cavities. It is a sphincter-saving procedure and offers many advantages to patients. Our initial results with the procedure are quite encouraging.

Role of video assisted anal fistula treatment in our management of fistula-in-ano

Background: Video-assisted anal fistula treatment is a new method used for treatment of complex perianal fistula with maximal sparing of sphincter muscles and prevention of false route. Authors inform about their experience and operative results. Aims: Our aim was to verify feasibility of the method, help in internal opening identification and define its position in our management of perianal fistulas. Methods: Patients with chronic fistula-in-ano of IBD and non-IBD benign etiology were enrolled. Anoscopy with fistuloscopy was attempted in all patients followed by loose seton drainage or other procedure. Results: Fistuloscopy was attempted in 30 patients, finished in 93% and internal opening was found in 67%. No procedure-related morbidity was observed. Conclusion: Fistuloscopy alone is feasible for diagnosing type of IBD and non-IBD fistulas. VAAFT technique and instruments were helpful for identification of an internal opening in most cases. As such it has established role in our management of fistula-in-ano.

Video-assisted anal fistula treatment: technical considerations and preliminary results of the first brazilian experience

BackgroungAnorectal fistula represents an epithelized communication path of infectious origin between the rectum or anal canal and the perianal region. The association of endoscopic surgery with the minimally invasive approach led to the development of the video-assisted anal fistula treatment.AimTo describe the technique and initial experience with the technique video-assisted for anal fistula treatment.TechniqueA Karl Storz video equipment was used. Main steps included the visualization of the fistula tract using the fistuloscope, the correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening which can be accomplished through firing a stapler, cutaneous-mucosal flap, or direct closure using suture.ResultsThe mean distance between the anal verge and the external anal orifice was 5.5 cm. Mean operative time was 31.75 min. In all cases, the internal fistula opening could be identified after complete fistuloscopy. In all cases, internal fistula opening was closed using full-thickness suture. There were no intraoperative or postoperative complications. After a 5-month follow-up, recurrence was observed in one (12.5%) patient.ConclusionVideo-assisted anal fistula treatment is feasible, reproducible, and safe. It enables direct visualization of the fistula tract, internal opening and secondary paths.

Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn’s disease

It was the aim of this prospective study to analyze both the feasibility and preliminary results of video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair for complex fistulas in Crohn's disease. All patients with perianal Crohn's disease suffering from complex fistulas who underwent definitive surgery using VAAFT combined with advancement flap repair were prospectively enrolled in the study. Only complex fistulas with concurrent stable disease and without any evidence of severe inflammatory activity or perianal sepsis were treated using the VAAFT technique. Patients with Crohn's proctitis or prior proctectomy were not candidates for the procedure. VAAFT was performed by using the VAAFT equipment (Karl Storz, Tuttlingen, Germany). Key steps included visualization of the fistula tract and/or side tracts using the fistuloscope and correct localization of the internal fistula opening under direct vision with irrigation. Diagnostic fistuloscopy was followed by advancement flap repair. In addition to feasibility, primary end points included detection of side tracts, success and continence status (assessed by the Cleveland Clinic Incontinence Score). Success was defined as closure of both internal and external openings, absence of drainage without further intervention and absence of abscess formation. Follow-up information was derived from clinical examination 3, 6 and 9 months postoperatively. Within a 3-month observation period (September to November 2011), VAAFT was attempted in 13 patients with Crohn's associated complex fistulas. The completion rate was 85% (11/13). In these 11 patients (median age 34 years, 64% females), complex fistulas were transsphincteric (8), suprasphincteric (2) and recto-vaginal (1). Forty-six percent (5/11) had concomitant therapy with biologic drugs. In 36% (4/11), VAAFT was performed with fecal diversion. Median duration of surgery was 22 (range 18-42) minutes. Using VAAFT, additional side tracts not detected preoperatively could be identified in 64% (7/11). No morbidity occurred. After a mean follow-up of 9 months, the success rate was 82% (9/11). No deterioration of continence was documented (Cleveland Clinic Incontinence Score 2.4 vs. 1.6, p > 0.05). Preliminary results of the addition of the VAAFT technique to advancement flap repair in Crohn's fistulas demonstrate that this leads to a high identification rate of occult side tracts with encouraging short-term healing rates. Moreover, a completion rate of 85% seems promising.

Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas

Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas

Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas: response to comment by Chivate

Dr. Chivate [1] raises some important technical considerations pertaining to the ease (or otherwise) of the procedure [2]. We know, for example, from the work of Buchanan and colleagues that preoperative imaging does not readily identify the subepithelial course of fistulae, and this group has previously suggested that a more acute angle of entry of the fistula is associated with a higher traversal through the sphincteric musculature [3]. These fistulae, more angled at their point of entry, may result in more sphincter destruction when conventional means of treatment particularly where larger staple ‘‘volcanoes’’ may need to be created to establish closure of the presumptive internal opening. It would be of interest to know the histology of these volcano excisions and whether they contain internal sphincter muscle. We now have glues, plugs, LIFTs, BIOLIFTs, FilAC lasers, regenerative cells, advancement anoplasties (with or without internal sphincter division) and now VAAFT for the treatment of complex recurrent fistulae. When each is suitable or contraindicated is at present unclear and like all of our fistula literature, this will depend on the longer term fidelity of our follow-up, our recording of specific procedure-related complications and particular fistularelated functional quality of life estimates. These data simply are not yet available. The VAAFT offers a nice minimally invasive approach with small wounds and limited sphincteric damage, it lends itself to repeat surgery should it fail, and it is unlikely to compromise the chances of repeat-VAAFT success. I too am interested in what to do with that very angulated or circuitous fistula which the VAAFT scope cannot negotiate. Further, can VAAFT deal with the obtuse side track or the fistula lying in an abscess cavity and disconnected from its proximal extension? What are the best electrodes to employ with VAAFT and should volcanoes be supported by mucosal advancement? Finally, what do we do in those cases where there is no visible external fistula opening?

Comment on Meinero and Mori: Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas

Comment on Meinero and Mori: Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas

Erratum to: Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas

Erratum to: Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas

“Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas” by Piercarlo Meinero and Lorenzo Mori

“Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure to repair complex anal fistulas” by Piercarlo Meinero and Lorenzo Mori

Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas

BackgroundVideo-assisted anal fistula treatment (VAAFT) is a novel minimally invasive and sphincter-saving technique for treating complex fistulas. The aim of this report is to describe the procedural steps and preliminary results of VAAFT.MethodsKarl Storz Video Equipment is used. Key steps are visualization of the fistula tract using the fistuloscope, correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening using a stapler or cutaneous-mucosal flap. Diagnostic fistuloscopy under irrigation is followed by an operative phase of fulguration of the fistula tract, closure of the internal opening and suture reinforcement with cyanoacrylate.ResultsFrom May 2006 to May 2011, we operated on 136 patients using VAAFT. Ninety-eight patients were followed up for a minimum of 6 months. No major complications occurred. In most cases, both short-term and long-term postoperative pain was acceptable. Primary healing was achieved in 72 patients (73.5%) within 2–3 months of the operation. Sixty-two patients were followed up for more than 1 year. The percentage of the patients healed after 1 year was 87.1%.Conclusions The main feature of the VAAFT technique is that the procedure is performed entirely under direct endoluminal vision. With this approach, the internal opening can be found in 82.6% of cases. Moreover, fistuloscopy helps to identify any possible secondary tracts or chronic abscesses. The VAAFT technique is sphincter-saving, and the surgical wounds are extremely small. Our preliminary results are very promising.