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Fistula Treatment

Laser treatment for fistula in ano- A sphincter saving approach

AETIOLOGY

  • Infection of the crytoglandular glands extending to the intersphincteric space leading to abscess formation which ultimately drains into the perineum leading to a track lined by granulation tissue and epithelial cells with an inner and outer opening.
  • Secondery fistula- crohns, tb,lgv, trauma etc

FISTULA IN ANO

  • DEFFINITION : A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation tissue and that connect a primary opening inside the anal canal to a secondary opening in the perianal skin. Secondary tracts may be multiple and can extend from the same primary opening
  • CRYPTOGLANDULAR FISTULA
  • NON CRYPTOGLANDULAR FISTULA

AIM FOR THE IDEAL TREATMENT OF ANAL FISTULA

  • Eradicate sepsis
  • Promote healing of the tract
  • Preserving sphincters and mechanism of continence
  • Low rate of recurrence

METHODS FOR THE TREATMENT OF ANAL FISTULA

  • Conventional laying open of the fistulous tract
  • Seton
  • Lift/bio-left
  • Anal fistula plug
  • Fibrin glue
  • Video-assisted anal fistula treatment
  • Laser fistula closure
  • Adipose-derived stem cell

LASER IN THE MANAGEMENT OF FISTULA IN ANO

  • Laser fistula closure (filac) method
  • Distal laser with proximal ligation (dlpl) method

PROCEDURE FOR FILAC

  • 1470nm/980 nm diode laser
  • 600 micron radial laser emitting fiber(360 degree fiber)
  • Laser energy is emitted from the up at 360 degree
  • Energy causes shrinkage of the tissue and leading to the clouser of the tract.
  • Fiber is slowly withdrawn at 1mm/sec
  • 10w-12w energy per second is usually delivered
  • Limited radial penetration depth (2-3mm beyond the fistula track)

WHETHER TO CLOSE THE INTERNAL OPENING?

  • Non closure
  • Mucosal advancement flap
  • Anodermal flap

NON CLOSURE OF THE INTERNAL OPENING

  • The FiLaC approach is designed to destroy both the crypt gland and the additional epithelial layer of the fistula track simultaneously by a photothermal effect with coincident obliteration of both the internal and external fistula orifices.
  • RECURRENCE RATE : Higher
  • EXPLANATION : The result of fistula re-opening with a linking up of the epithellal remnants of small undetected secondary tracks before the denaturaion effect of the laser can take effect.

DLPL-DISTAL LASER PROXIMAL LIGATION

  • 1470nm /980nm DIODE LASER
  • 600micron Radial Laser Emerging Fiber
  • Identifying The Tract And Inner Opening By Gentle Probing Or Hydrogen Peroxide
  • Dissecting The Tract In Between The External And Internal Sphincteric Plane
  • Ligating The Tract Near The Mucosa And Cutting It.
  • The rest of the tract was treated as per the Filac procedure.

CLOSURE OF THE INTERNAL OPENING

  • Recurrence Rate : Less
  • Preferred
  • Complicated Fistula

LITERATURE REVIEW

  • Primary Healing Rate 06.2%
  • Secondary Healing Rate 05.5%
  • Primary Healing Rate 71.4%
  • Primary Healing Rate : 81.8%

COMPLICATIONS

  • IMMEDIATE : BLEEDING
    BURN
  • DELAYED : INCONTINENCE
    FAILURE OF CLOSURE
    ABSCESS FORMATION

COMPARING DLPL AND FILAC

DLPL

  • For Complex Fistula
  • Dissection Of The Intersphincteric Plane Required
  • If Interspincteric Absess is Present It Gets Drained
  • Recurrence Rate Is 5%
  • No Sphincter Injury

DLPL

  • For Straight Fistulous Tract
  • No Such Dissection Required
  • No Drainage
  • Recurrence Rate Is 15%
  • Quicker Post Op Recovery
  • No Sphincter Injury

LASER AS AN IMPORTANT TOOL FOR PROCTOLOGIST

  • LASERS provide newer treatment options.
  • providing faster recovery.
  • Lesser pain.
  • Better outcome of surgery.
  • Smaller wounds
  • Making proctology a day care procedure

HAEMORRHOIDS

  • World wide prevalence from 2.9% to 27.9%
  • Men more the females
  • Effects at middle age
  • The anorectal vascular cushions along with the internal anal sphincter are essential in the maintainence of continence by providing soft tissue support and keeping the anal canal closed tightly.
  • There are typically three major anal cushions , located in the right anterior, right posterior and left lateral aspect of the anal canal and various numbers of minor cushions lying between them

GRADATION OF HAEMORRHOIDS

Internal Hamerrhold Grades

  • No prolapse, just prominent blood vessels

  • Prolapse upon bearing down, but spontaneous reduction

  • Prolapse upon bearing down requiring manual reduction

  • Prolapse with inability to be manally reduced