Laser Surgery For Fistula

Anal fistula (or fistula-in-ano) is a small hollow tunnel that runs from the anal canal through an opening inside it to an outside opening over the skin around the anus.

What causes fistula in ano?

An anal fistula commonly occurs from an infected anal gland and develops a pus-filled area (abscess). A fistula (usually complex) can also happen with certain conditions such as Crohn’s disease. Or it may arise due to radiation therapy for cancer. Injury to the anal canal and surgery can also cause anal fistulas, says Dr. Purnendu Bhowmik, one of the best fistula doctors in Kolkata, associated with Clinica Health.

Should you treat fistula in ano?

Yes. It must be treated because it doesn’t heal on its own. There is also a risk of developing cancer in the fistula tract if left untreated for a long period of time.

Can fistula be cured?

Yes. A well planned and well executed fistula surgery by the best proctologist in Kolkata can offer complete cure. Most fistulas are simple to treat. But few may pose difficulty when they are complex in nature.

What are the treatment options for fistula?

  • Below is a list of procedures which are used to treat fistula. Each procedure has its own pros & cons.
  • Fistulotomy/ fistulectomy
  • Seton techniques
  • Advancement flap procedure
  • LIFT procedure
  • Endoscopic ablation
  • Laser surgery (FiLaC/LAFT)
  • Fibrin glue
  • Bio prosthetic plug.

What are the side effects of conventional fistula surgery?

  • Partial anal stenosis (due to fibrosis during the healing of large perianal wound)
  • Infection
  • Loss of bowel control (incontinence)
  • Fistula recurrence
What happens if you develop partial anal stenosis following conventional fistula surgery?
  • Lifelong medication to pass motion
  • Straining & bleeding during passage of stool
  • Abdominal pain due to secondary constipation

What is laser fistula treatment in Kolkata?

The laser surgery for fistula or FiLaC is a minimally invasive surgery in the treatment of anal fistulas. Fistula Laser Closure (FiLaC) is comparativelya new surgical technique inwhich the fistulous tract is ablated using a ‘radial laser fibre’ resulting in destruction of the fistula walls and granulation tissue followed by shrinkage and subsequent closure of the tract.

Is laser treatment safe for fistula?

Yes. Laser closure of fistula is a very safe and painless treatment for fistula in ano specially in cases of transphincteric and high anal fistulas where conventional surgical procedure is associated with the risk of injury to the anal sphincter (circular muscle) resulting in post-operative faecal incontinence.

How long is recovery from laser fistula surgery?

In conventional surgery for fistula, it usually takes about 6 weeks to 8 weeks for your wound to completely heal. Whereas, in laser closure, it takes only few days to recover and go back to one’s regular activities.

What are the benefits of laser surgery for fistula over the other conventional surgical options?

There are many advantages of laser surgery for fistula over conventional surgery.

Fistula

What our patients say

Anal fistula is a an abnormal communication between the anorectal canal and the perianal skin that is lined with granulation tissue. It occurs as a result of an anorectal abscess, which was previously drained. While the abscess is the acute phase of the disease, fistula represents the chronic phase.

How does it develop?

Infection of the glands in the intersphincteric space between the EAS and IAS is thought to be the primary cause of both acute anorectal abscesses and anal fistulas —the ‘cryptoglandular hypothesis’

How are fistulas classified?

  • Different systems of classification have been described, but the most useful and widely accepted classification is the one described by Parks. This system is based on the communication between the primary track, which includes the main tunnel constituting the fistula and the sphincter muscles surrounding the anal canal.
  • Intersphincteric (45-60%): do not run through the external sphincter, but traverse the longitudinal muscle layer between the external and internal sphincters towards the perineal skin.
  • Suprasphincteric (3%): fistulas track upwards through the intersphincteric space and then arch downwards and cross the levator muscle, reaching the ischiorectal fossa and then the skin.
  • Transphincteric (25-30%): the track crosses the external sphincter into the ischiorectal fossa before heading down to the perineum
  • Extrasphincteric (<3%): have a more proximal origin, and cross the levator muscles to reach the ischiorectal fossa. The anal sphincter complex or anal canal does not play a part here.
Considering the origin of the disease, fistulas may be categorized as:
  • specific or secondary to pathological process, such as ulcerative colitis, tuberculosis, Crohn’s disease, trauma, and other morbid conditions; and
  • nonspecific or secondary to infection of the anal glands.
Imaging

When it comes to diagnosing fistula anatomy, MRI is considered the “gold standard”.

Management options
  • Fistulotomy: Has a high success rate of 87-94%. It is used for intersphincteric, low transphincteric, and simple fistulas
  • Seton Placement: The primary application is in high trans-sphincteric fistula.
  • Fibrin Glue: Has the lowest success rates, 14-16%, but has low risk to sphincter musculature/incontinence since there is no dissection. Moreover, it is currently used as an adjunct to other treatments +/- advancement flap.
  • Anal Fistula Plug: Has a moderate success rate of 35-85%. Does not have any or low impact on sphincters, and continence used for low transphincteric fistulas. It has the highest rate of post-opertive septic complications.
  • Endoanal/rectal advancement flap: Has a success rate of 62-88%. It has low/no incontinence rates, as this is a sphincter sparing procedure.
  • Ligation of intersphincteric fistula tract (LIFT): Has a moderate success rate of 57-94%. It has low incontinence rates and is used for transphincteric fistulas, which converts hard-to-treat transphincteric fistula to an easier-to-manage intersphincteric fistula
  • BioLIFT: LIFT with the addition of a bioprosthetic in the intersphincteric plane
  • Defunctioning: In rare cases where perianal sepsis is difficult to control and multiple tracks exist, a colostomy is done to defunction the rectum and anal canal.
  • Stem cells: The use of stem cells is a novel treatment. In this,the patient’s own adipose tissue is processed and centrifuged to provide adipose derived stem cells. These cells were cultured and injected into the fistula track. However, this technology is not available in most centres.

Special cases

Crohn’s disease

The cumulative incidence of anal fistula in patients with Crohn’s disease is 20-25%. Fistulas are often complex and multiple; this makes the treatment difficult. In this case, anti-tumor necrosis factor-α therapy is considered the first-line treatment. Surgical options are considered if medical treatment fails, but because of the poor rate of wound healing in active Crohn’s disease, a defunctioning colostomy is a more common strategy.

Tuberculosis

Tuberculosis may be the cause of anal fistula in some cases. Tuberculosis should be suspected in patients who fail to respond to standard treatment or who develop recurrent fistulas. Diagnosis is made through the histological finding of granulomatous disease and the positive identification of acid fast bacilli. Antituberculous drugs are the first line treatment.

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