|Year : 2020 | Volume
| Issue : 6 | Page : 211-215
Video-assisted anal fistula treatment: A single-center experience to opt the right tract
M Suyambu Raja, Anoop Vasudevan Pillai, Riju Ramachandran
Department of General Surgery, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
|Date of Submission||07-May-2020|
|Date of Decision||23-May-2020|
|Date of Acceptance||06-Aug-2020|
|Date of Web Publication||19-Dec-2020|
AG-1, Sterling Sarovar, Kosseri Lane Edapally, Kochi - 682 024, Kerala
Source of Support: None, Conflict of Interest: None
Background: Fistula-in-Ano is common in clinical practice and is notorious for morbidity and recurrence with current treatment options. Minimal invasive procedure is being tried with encouraging results.
Materials and Methods: This is a series of 35 patients who underwent video-assisted anal fistula treatment (VAAFT) in our institution from 2015 to 2018. All patients were evaluated both clinically and with magnetic resonance imaging to delineate the details of the fistula. Patients were treated by VAAFT and followed up for 12 months. The data were acquired from the hospital information system. Failure of the procedure, recurrence, and any other adverse events were recorded correlating it with the gender, comorbidity, type of the tract, linearity of the tract, and relation to the levator ani muscle. Chi-square test with continuity correction was used to find the association between recurrence and clinical parameters. Kruskal–Wallis test was used to compare the mean recurrence time among the type of fistula and tract.
Results: In the 27 males and 8 females, we found 22 patients had linear fistulous tract, 6 had linear bifurcated, curvilinear tract in 6, and 1 had a blind tract. The median operation time was 58 min. Healing rate was highest (72.7%) in patients who had a linear tract, and recurrence was highest (66.7%) in patients who had a curvilinear tract. Patients with blind tracts or multiple tracts identified at the surgery and those with Crohn's disease had a higher incidence of recurrence.
Conclusion: VAAFT can be recommended as an initial minimally, morbid, though expensive procedure in the management of the simple type of fistula-in-ano with an acceptable recurrence rate.
Keywords: Fistula in ano, proctology, surgical procedures
|How to cite this article:|
Raja M S, Pillai AV, Ramachandran R. Video-assisted anal fistula treatment: A single-center experience to opt the right tract. Formos J Surg 2020;53:211-5
|How to cite this URL:|
Raja M S, Pillai AV, Ramachandran R. Video-assisted anal fistula treatment: A single-center experience to opt the right tract. Formos J Surg [serial online] 2020 [cited 2022 Aug 11];53:211-5. Available from: https://www.e-fjs.org/text.asp?2020/53/6/211/304023
| Introduction|| |
Fistula-in-ano is a chronic sequel of crypto glandular sepsis, resulting in an epithelized communication between the rectum or anal canal with the perianal region. Medical literature traces the disease to 400 BC in writings of Hippocrates and the famous playwright William Shakespeare. It is classified as intersphincteric (70%), transphincteric (25%), suprasphincteric (5%), extraphincteric (1%). The treatment options are many and include open and minimally invasive procedures. Open procedures include fistulotomy, fistulectomy with seton insertion, flap advancement procedure. Minimal invasive procedures include video-assisted anal fistula treatment (VAAFT), over-the-scope proctology clip system, and fistula tract laser closure, fibrin sealants/plugs. Although fistulotomy is a simple, widely accepted treatment for a low fistula, treatment for more complex and high fistula is controversial and remains a nightmare for surgeons. However, the need for long-term follow-up, daily dressing, pain, affecting regular activities, discomfort, and fecal incontinence are common with the conventional procedure. This created the need for an alternate sphincter function preserving surgery. This study aims to highlight our experience of anal fistula treated with video-assisted anal fistula treatment introduced by Meinero as an alternate option for managing complex anal fistulae and its efficacy in the management of anal fistulae.
| Materials and Methods|| |
Ours is a single centered retrospective study of all patients who underwent video-assisted anal fistula treatment consecutively from 2015 to 2018 at a tertiary care center. All procedures were done by the senior consultant (corresponding author) of the department of general surgery who had experience in this procedure for 8 years to avoid inter-operator variation. The patient details were obtained from the register maintained in the operation theatre. The demographic details of the patient and the details regarding the type of tract, the linearity of the tract, relation to the levator ani muscle were acquired from the hospital information system (HIS) database. The details collected were entered into an excel sheet.
In our unit all the patients who were diagnosed with fistula in ano, were evaluated initially with magnetic resonance (MR) fistulogram to get details of the type of tract– intersphincteric, transsphincteric or suprasphincteric, direction of the tract– linear or curved, relation to the levator ani muscle. The patients were then taken up for surgery. The patient was asked to take only clear liquids on the day before surgery. Preoperatively, a dose of ciprofloxacin and metronidazole was given and was continued for 5 days postoperatively. Bowel preparation was done with Polyethylene glycol the previous night and a soap and water enema in the morning of surgery.
An 8° angled rigid scope with a working and irrigation channel manufactured by Karl Storz© was used for the procedure. The scope's operating length is 18 cm, and the external diameter of 3.3 mm × 4.7 mm. The procedure was done under spinal anesthesia. Depending on the location of the external opening, the patient was positioned either in lithotomy or jackknife position. A solution containing 1% Glycine was used for irrigation. We did the VAAFT procedure in two phases-diagnostic phases and then the operative phase. In the diagnostic phase, we passed the scope through the external opening, and the entire length of the fistulous tract was mapped. We looked for any secondary tracts, unidentified abscess cavity, and confirmed the position of the internal opening. Once the tract was mapped, the treatment phase was started by fulgurating the circumference of the wall of the tract in its whole length using a monopolar electrode under direct vision. A grasper and then an endobrush were used to remove necrotic material and the fulgurated granulation tissue. The tract was reinspected, and the procedure was repeated until the entire tract was treated satisfactorily. Either a stapler or absorbable suture was used to close the internal opening. In the early part of the practice, the internal opening was closed using a stapler, but later, it was changed to suture closure using 2-0 vicryl. The mucosa around the internal opening was fulgurated, and a mucosal patch using the adjacent tissues was done to cover the opening based on the literature on direct closure of fistula with an advancement flap. Fibrin sealant was placed at the closed internal opening, and the length of the tract was filled with it. Postoperatively, the patients were started on liquid diet after 4 h, followed by a soft diet. All patients were discharged on the 1st postoperative day with laxative, stool softeners and pain medications in case needed. Very few patients required analgesia after the 1st postoperative day. The procedure was considered a failure when there was discharge of fluid lasting >3 weeks. Recurrence was considered in the healed fistula when there was a new discharge of fluid.
Data collection and follow-up
The data were acquired from the HIS. The patients were followed up at 1, 3, 6, and 12 months postoperatively by clinical examination of the perianal region looking for any discharge from the treated fistula or any new opening. Failure of the procedure, recurrence, and any other adverse events were recorded. The healing rate and the recurrence rate associated with the procedure was analyzed correlating it with the gender, comorbidity, type of the tract, linearity of the tract, and relation to the levator ani muscle.
Statistical analysis was performed using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, N.Y., USA. Categorical variables are expressed using frequency and percentage. Numerical variables are presented using mean and standard deviation. Chi-square test with continuity correction was used to find the association between recurrence and anal fistulae in relation to levator ani. Kruskal–Wallis test was used to compare the mean recurrence time among the type of fistula and tract. A value of P < 0.05 was considered to be statistically significant.
Ethical clearance is given and approval of the study is granted by IRB meeting held on Sep. 15th, 2020 of AMRITA Institute of Medical Sciences (No. IRB- AIMS-2020-244). General informed consent has been taken from all patients for use of relevant clinical and surgical information in an anonymous way.
| Results|| |
A total of 35 patients in whom VAAFT was performed were followed up at 1, 3, 6, and 12 months postoperatively. The median follow-up duration in these patients is 192 days (12–892 days). The baseline demographic and clinical parameters studied are listed in [Table 1]. Of the 35 patients, there were 27 males and 8 females with a median age of 36 (range 17–64). A previous history of perianal abscess treated with incision and drainage was present in 28 patients and 3 of them had earlier been diagnosed with Crohn's disease.
There were 15 patients with transphincteric fistula, 13 had intersphincteric fistula, 7 had extrasphincteric fistula. Review of the preoperative MR imaging (MRI) showed 22 patients had a linear fistulous tract, 6 had linear bifurcated, curvilinear tract in 6, and 1 had a blind tract. The median operation time was 58 min (range 40–100 min). All the patients returned to routine life within 5 days. There was no need for daily dressing. A detailed description of the nature of the tract in terms of number of tracts, number of external and internal openings and their impact on recurrence is given in [Table 2]. The patients who had multiple tracts detected intraoperatively had the maximum recurrence. There is no significant difference of recurrence in patients having more than one internal or external openings. On follow-up, the healing rate was highest (72.7%) in patients who had a linear tract and recurrence was highest (66.7%) in patients who had a curvilinear tract. Recurrence was seen in 14 patients. Patients with blind tracts or multiple tracts identified at surgery had a higher incidence of recurrence (single tract [5/14] 35%, multiple tract [9/14] 64.2% and blind tract [7/14] 50%). The mean duration for a recurrence to occur was 50 days in linear bifurcating tract and 202 days in patients with a curvilinear tract [Table 3]. In relation to levator ani muscle, tract which had a superior extension had a recurrence rate (100%) compared with the patients who had extension inferior to levator ani (25%) with a significant P value (0.001) [Table 3]. Complete healing without recurrence was seen in transphincteric fistula tract (80%) followed by extrasphincteric tract (71.4%) and the recurrence rate was highest (69.2%) in intersphincteric type of fistula with an early mean duration of 120 days for recurrence postsurgery [Table 3]. [Table 4] shows a comparison of the recurrence in patients having simple versus complex fistulae. Patients with Crohn's disease had a significant recurrence rate of 100%. Though the incidence of fistula-in-ano was higher in males (27), the recurrence rate was more in females (62.5%). There were no patients with incontinence after the procedure. Few patients reported blood-stained discharge from the external opening for up to 3 weeks before complete healing. Our patients had no complications except recurrence in fourteen patients. Of the fourteen patients, seven underwent fistulectomy with seton placement later. Four patients were taken up for a repeat VAAFT, but in this set of patients, we used autologous platelet-rich fibrin (PRF) instead of fibrin glue to fill the treated tract. These patients healed completely. Three of the patients are lost to follow-up.
| Discussion|| |
Fistula-in-ano is often preceded by crypto glandular sepsis. Intersphincteric tracts or single trans-sphincteric tract that crosses <30% of the external sphincter are considered as simple fistulae. Complex fistulae include high transphincteric, suprasphincteric, extrasphincteric, recurrent and horseshoe fistula, multiple tracts, anteriorly lying tracts in female patients and those associated with inflammatory bowel disease, radiation, preexisting incontinence, or chronic diarrhea.
Anal fistulae management ranges from open fistulotomy to a colostomy. In our experience for the past 18 years of treating anal fistulae, fistulotomy/fistulectomy had a significant healing rate (96%) with significant morbidity involving delayed wound healing, recurrence, wound discharge, and fecal incontinence affecting the quality of life, similar to published literature. In simple and low fistulae, fistulectomy has a high success rate (100%), which is significantly reduced in complex and high anal fistulae.,, The principle behind traditional surgical management was identifying and laying open the fistula tract. However recurrence occurred due to incomplete identification of the primary tract and secondary tract. Further need for multiple sessions of treatment as in a seton tightening, the increased cost incurred, and the residual complications of these procedures pushed us to this minimally invasive alternative.
Athanasiadis et al. proposed a technique of direct closure of the internal opening of the fistula without advancement flap. It is a three-layered nonstaggered closure of the mucosa, submucosa, internal and external sphincter after excision of the entire fistula tract along with the internal and external opening. Literature reported the success rate of the procedure as 59% with a drawback of suture line dehiscence and persistence or recurrence of fistula. We modified our procedure by using staplers to using absorbable suture based on this principle. However, many of these methods fail to fulfill the main principles of treating anal fistula, which is the identification of the tract and its internal opening, excision or destruction of the tract, and preservation of the sphincter function.
Meinero, in 2006, introduced VAAFT as a sphincter function preserving surgery for the management of complex anal fistulae. This involves direct visualization of the fistulous tract and identification of any underlying cavities or unidentified tract and destruction of the tract. The principle benefit of this procedure is its repeatability until success achieved without affecting the anal sphincter complex. VAAFT has very minimal postoperative morbidity like minimal loss of quality of working days, postprocedure pain, and no residual perianal wound compared to other conventional procedures.
This procedure was performed in our institute after an appropriate case selection of patients with the help of an MR fistulogram. The benefit of preoperative MR fistulogram is in detecting the feasibility of opting for VAAFT and to preoperatively map and number the fistula tracts to be tackled, their extent and relation with the levator and sphincter complex. Although MRI slightly increases the initial investigation cost, it greatly adds to the overall success rate in treating the fistula, thereby giving an excellent cost-benefit ratio.
Blind tracts are an enigma detected by MRI (n = 1) [Table 1]. Sometimes a well-defined tract seen on MRI may turn out to be a blind tract during the procedure (n = 3) [Table 2]. In some of these patients, we were unable to maneuver the fistuloscope across the internal opening due to stenosis. Patients having multiple tracts and branches were identified with MRI and were confirmed during VAAFT. VAAFT did not have any added advantage in identifying any additional branch/tracts. However, doing the MRI gave us a complete mapping of the fistula, which helped us in planning the procedure.
Due to the complex anatomy of the pelvic structures, the anal fistulae vary in their course, size, and shape. With the rigid scope, it becomes difficult in maneuvering through the entire fistulous tract, which makes it an incomplete treatment, further leading to recurrence at some point of time. Furthermore, the collateral thermal damage while fulgurating the tract is expected. This procedure has less morbidity compared to the conventional treatment modalities for managing fistula in ano. The reported healing rate of this procedure approximately varies from 65% to 85% in the literature.
In our study, the success rate of the procedure is 60% and a recurrence rate of 40%. Recurrence was highest in patients who had intersphincteric type of fistula. When intersphincteric fistulae alone were reviewed critically, we found recurrence was higher if it was curvilinear, extended superior to levator or was blind-ending [Table 5]. Simple linear tracts had a good success rate. When we compared the treatment results of simple and complex fistulae [Table 4] in the series, there is a statistically significant increase in recurrence in patients having complex fistulae. As can be seen from [Table 3], the cause for recurrence was blind tracts, Crohn's disease, curvilinear tracts and tracts superior to levator. These are conditions which reduce the maneuverability of the scope and also the disease process like Crohn's where recurrence may occur de novo. Hence in such difficult cases, VAAFT can be considered as an initial minimally morbid procedure, and in case of a recurrence, the second session of VAAFT or another technique can be offered.
Usually, stenosis of the tract at the internal opening area is the reason for a blind tract. But the area of the internal opening can be visualized using an anoscope and the light from the fistuloscope emanating from the area. This area is tagged and closed, as described in the methods. The inability to identify the internal opening (blind tracts) or patients having multiple tracts increases the possibility of patients having a recurrence. When all the tracts, branches and internal openings were properly identified and addressed, the procedure had a very high success rate. This fact can be seen from the existing literature on this procedure.
Even though the initial cost of VAAFT is high, the reduced morbidity, shorter hospital stay, and the reduced loss of quality working days make this a better option compared to the traditional procedure with high morbidity, multiple hospital visits and procedures which further increases the cost of the total treatment process.
Most literature suggests better results in female patients undergoing VAAFT. However, we found that in our series, the recurrence rate was slightly higher in female patients as compared to male patients. The reason for this variation in our population will need to be further studied. The major limitation of this study is the limited number of patients. This study is being continued with the use of autologous PRF for the closure of the fistulous tract post VAAFT.
| Conclusion|| |
VAAFT can be recommended as an initial minimally, morbid, though expensive procedure in the management of the simple type of fistula-in-ano with acceptable recurrence rate.
Financial support and sponsorship
The study has been supported by Amrita institute of medical science, however there were no funds involved.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]