Introduction

Anal Fistula is an abnormal passage (communication) between the interior of the anal canal or rectum and theskin surface around the anus.

Causes of Anal Fistula

• Cryptoglandular
• Inflammatory bowel disease
• Crohn’s disease
• Ulcerative colitis

Infection

• Tuberculosis
• Actinomycosis
• Lymphogranulomavenereum

Trauma

• Impalement Foreign body

Surgery Trauma

• Episiotomy
• Hemorrhoidectomy
• Prostatectomy

Malignancy

• Carcinoma
• Leukemia
• Lymphoma

Radiation

Symptoms of Anal Fistula

• Symptoms are usually a purulent discharge and drainage of pus and/or stool near the anus, which can irritate the outer tissues causing itching and discomfort.
• Pain occurs when fistulas become blocked and abscesses recur.

Types of Anal Fistula

For practical purposes, Anal Fistula are 2 types - Low & High. Low Fistula are present in the lower part and do not extend up to the ano-rectal sling [ muscle layer responsible for continence (control on passage of motions)]. High fistula extend up to or beyond ano-rectal sling. Knowing the type of fistula is important because high fistula if not managed properly can be associated with incontinence.[loss of control on passage of motions]

How to diagnose Anal Fistula ?

• Fistula probe
• Anoscope [Proctoscope]
• Fistulography
• Endo Anal Ultrasound
• Magnetic resonance imaging
• Fistula Scope

Surgical Approaches Fistula InAno

Conventional techniques

• Fistulotomy with Marsupalization
• Fistulectomy

Minimal Invasive Techniques

(Trend towards sphincter-saving approaches- Without Cutting)

• Fistula Laser Closure ( FiLaC )
• Distal Laser Proximal Ligation ( LIFT with Laser )
• Distal Laser Proximal SLOFT ( DLPS )
• Fixcision ( Fistula Tract Coring ) with Proximal SLOFT
• VAAFT with LASER

Fistula – tract Laser Closure (FiLaC®)

FiLaC® is a treatment for anal fistulas, which manages to avoid surgical incision and postoperative fecal incontinence (sphincter-saving technique).

A Laser catheter is inserted from the cutaneous opening of the fistula. The catheter reaches the anal opening, where the inflammatory tissue which is responsible for the creation of the fistula is cauterized. During the gradual exit of the laser-catheter, the granulomatous tissue is cauterized until the outer skin opening. Until now, the initial

Advantages

• Minimal Invasive Procedure
• High Success Rate
• Minimal Post-Operative Pain
• Short Hospital Stay
• No Post Operative Dressings
• Less Financial Burden
• Faster Return to Work

VAAFT Procedure for fistula in Ano

Video Assisted Anal Fistula Treatment “A New Technique for Complex Anal Fistula Treatment”

Features of VAAFT

• Under vision
• I.O. hermetic closure
• No surgical wounds

Advantages of VAAFT

• No surgical wounds
• Correct location of the internal opening
• Destruction of the fistula from the inside
• No importance of the fistula classification
• No anal sphincter damages – no incontinence
• The patients have no need for medication
• Early resuming working activities (2-3 days)
• Not necessary any preoperative exam
• VAAFT is performed in day-surgery.

SLOFT

A new way to deal with internal opening in Fistula in Ano

Principle of dealing with Fistula in Ano

• Dealing with internal opening-Blocking the in fection
• Clearing the crypto-glandularsepsis
• Taking care of the distaltract

Dealing with internal opening

• Stapler of VAAFT
• Mucosaladvancementflap
• PLUG
• Excisionandfigureof8suturing
• Fibringlue
• LIFT
• SLOFT

What is DLPS ?

DLPS is Distal Laser and Proximal SubmucosalLigation of Fistula Tract (SLOFT)

Advantages of SLOFT and Laser ( DLPS )

• Ease to carry out the procedure
• Complete separation of the tract having cryptograndular infection
• Laser coagulation of Distal Tract leading to enhanced healing
• Least chances of recurrence

LIFT Technique for Fistula in Ano

LIFT technique is the novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of intersphincteric fistula tract) procedure.

The procedure was developed by Thai colorectal surgeon, ArunRojanasakul, Colorectal Division Department of Surgery, Chulalongkorn University in Bangkok, Thailand.

Surgical technique

• Identify the internal opening
• Incision at intersphincteric groove
• Dissection through intersphincteric plane to find intersphincteric fistula tract
• Secure suture ligation of intersphincteric fistula tract
• Remove the fistula tract
• Curette fistula tract from external opening
• Suture closure of external sphincter muscle defect
• Closure of intersphincteric wound

Fistula Tract Coring

Another method to treat Fistula in Ano.

Advantages

• Minimal Invasive procedure as compared to Fistulotomy or Fistulectomy
• No Large wounds created
• Minimal tissue trauma
• Faster healing time