Internal Orifice Alloy Closure-A New Procedure to Treat Anal Fistula.

Background: The internal orifice plays an important role in the pathogenesis and treatment of the most complex fistula-in-ano. The treatment of the internal orifice is considered to be the key to the success of anal fistula surgery. The objective of this study is to evaluate the feasibility of a new sphincter-sparing surgical approach for anal fistula. Materials and Methods: All hospitalized anal fistula patients were included in this study. Preoperative anorectal ultrasound was done on all the patients. Transanal internal orifice alloy closure (IOAC) was performed through a disposable titanium nickel alloy anal fistula stapler. The external sphincter was not cut. An anal fistula brush was used to curette and clean fistulas. Postoperative anorectal color ultrasound was used for evaluation 2 months postoperatively. Results: Twenty-one patients (male/female: 18/3, age: 39.7 ± 10.5 years) with fistula-in-ano were included (follow-up: 6-11 months).In total, 38.1% (8) had multiple tracts, and 9.5% (2) belonged to a high anal fistula. In total, 23.8% (5) of anal fistula patients were complicated by Crohn's disease. The fistula healed completely in 85.7% (18/21) and did not heal in 14.3% (3/21). Three patients who did not heal had conventional surgery reperformed and eventually healed. Except for three patients undergoing additional traditional anal fistula surgery, the Wexner incontinence scores of other patients did not change after surgery compared with before surgery. Conclusions: IOAC is a novel sphincter-saving technique that is simply effective in treating anal fistula containing Crohn's anal fistula.

Laser ablation of fistula tract (LAFT) and complex fistula-in-ano: "the ideal indication" is becoming clearer .

BACKGROUND: An initial study enabled us to achieve 60% healing of high transsphincteric fistula-in-ano with laser ablation of fistula tract (LAFT) The purpose of this new study was to investigate other predictors of the success of this technique in the treatment of complex anoperineal fistulas. METHODS: All patients treated with LAFT in our department between May 2017 and October 2018 were included prospectively. LAFT was used for patients with complex anoperineal fistulas who were at high risk of anal incontinence after fistulotomy. The fistula was considered healed when the internal and external openings were closed and the patient experienced no pain or leakage. RESULTS: A total of 100 consecutive patients (65 males) with a median age of 43 years (range 22-88 years) were included in the study. Eight patients were lost to follow-up. The fistulas were low (8%) or high (79%) transsphincteric, and suprasphincteric (13%). After a median follow-up of 13.6 months (range 6-23 months), fistula healing was observed in 41 patients (44.6%). On univariate analysis, an anterior location, a narrow internal orifice and administration of less than 400 J of energy were significantly associated with healing. On multivariate analysis, a narrow internal orifice and low energy administration remained significant predictive factors of success [OR 5.08 (1.03-25.03), p = 0.046; OR 2.59 (1.08-6.17), p = 0.032]. No new cases of anal incontinence or any worsening of pre-existing anal incontinence was observed during follow up. CONCLUSIONS: This study indicates that complex anoperineal fistulas with a narrow internal orifice can be successfully treated with less than 400 J and are ideal for LAFT.

Anal Fistula Laser Closure: the length of fistula is the Achilles' heel.

BACKGROUND: Laser closure is a novel sphincter-saving technique for the treatment of anal fistula. The aim of this study was to report middle term results of laser treatment without closure of the internal orifice and to identify prognostic factors to improve selection criteria and maximize healing. METHODS: A retrospective observational study was conducted on patients treated with laser for transphinteric anal fistula. A diode laser emitting laser energy of 12W at a wavelength of 1470 nm was used. The relationship between fistula healing and age, sex, previous fistula surgery, location of fistula, and length of fistula tract was investigated. A successful outcome was defined by the complete healing of the surgical wound and external opening for at least 6 months. RESULTS: Thirty patients (16 males, median age 52 years, range 26-72 years) underwent laser fistula closure between January 2015 and December 2016. Cure was achieved in 10 patients (33.3%). The mean follow-up was 11.30 months (range 6-24 months). Patients with persistent or recurrent fistula were offered repeat surgery. Eventually 4 underwent laser treatment once more. Two patients were cured leading to an overall healing rate of 40% (12 out of 30). Only 4 minor complications occurred (13.3%). No worsening of anal continence was registered. Only fistula length had a statistically significant correlation with successful treatment. Fistula tracts shorter than 30 mm were associated with a primary healing rate of 58.3% while tracts longer than 30 mm were cured in only 16.6% of cases (p < 0.02). CONCLUSIONS: Laser closure is a safe and effective treatment for transphinteric anal fistula. The fistula length is the only significant prognostic factor when closing anal fistulas exclusively with laser: shorter fistulas have a better outcome.