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      Five years of experience with the FiLaC™ laser for fistula-in-ano management: long-term follow-up from a single institution

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          Abstract

          Background

          There are limited data available concerning endofistular therapies for fistula-in-ano, with our group reporting the first preliminary outcomes of the use of the radial fibre Fistula laser Closing (FiLaC ™) device.

          Methods

          The aim of this study was to assess a cohort of anal fistulae managed with laser ablation plus definitive flap closure of the internal fistula opening over a long-term follow-up. Factors governing primary healing success and secondary healing success (i.e. success after one or two operations) were determined.

          Results

          The study analysed 117 patients over a median follow-up period of 25.4 months (range 6–60 months) with 13 patients (11.1%) having Crohn’s-related fistulae. No incontinence to solid and liquid stool was reported. Minor incontinence to mucus and gas was observed in two cases (1.7%), and a late abscess treated in one case (0.8%). The primary healing rate was 75/117 (64.1%) overall, and 63.5% for cryptoglandular fistulae versus 69.2% for Crohn’s fistulae, respectively. Of the 42 patients who failed FiLaC™ 31 underwent a second operation (“Re-FiLaC™”, fistulectomy with sphincter reconstruction or fistulotomy). The secondary healing rate, defined as healing of the fistula at the end of the study period, was 103/117 (88.0%) overall and 85.5% for cryptoglandular fistulae versus 92.3% for Crohn’s fistulae. A significantly higher primary success rate was observed for intersphincteric-type fistulae with primary and secondary outcome unaffected by age, gender, presence of Crohn’s disease, number of prior surgeries and the type of flap designed to close the internal fistula opening.

          Conclusions

          There is a moderate primary success rate using first-up FiLaC™ treatment. If FiLaC™ fails, secondary success with repeat FiLaC™ or other approaches was high. The minimally invasive FiLaC™ approach may therefore represent a sensible first-line treatment option for anal fistula repair.

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          Most cited references23

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          A classification of fistula-in-ano.

          A classification of anal fistulas is presented, which is the result of an analysis of 400 cases treated over the past 15 years, based on the pathogenesis of the disease and the normal muscular anatomy of the pelvic floor. Four main types were found but numerous variations of each occur, which are described. It is hoped that this will alert the surgeon to the various complex situations that he may encounter.
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            Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract.

            To describe a new technique for fistula-in-ano surgery aimed at total sphincter preservation, and evaluate the preliminary results concerning non-healing and intact anal function. A prospective observational study in eighteen fistula-in-ano patients treated by ligation of intersphincteric fistula tract (LIFT) technique, from January to June 2006. Fistula-in-ano in seventeen patients healed primarily (94.4%). There was one non-healing case (5.6%). The mean healing time was four weeks. None had disturbances in clinical anal continence. The early outcome of the LIFT technique is quite impressive. Results warrant a larger study with long-term evaluation. This technique has the potential to become a viable option for fistula-in-ano surgery.
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              Modern management of anal fistula.

              Ideal surgical treatment for anal fistula should aim to eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. For the simple and most distal fistulae, conventional surgical options such as laying open of the fistula tract seem to be relatively safe and therefore, well accepted in clinical practise. However, for the more complex fistulae where a significant proportion of the anal sphincter is involved, great concern remains about damaging the sphincter and subsequent poor functional outcome, which is quite inevitable following conventional surgical treatment. For this reason, over the last two decades, many sphincter-preserving procedures for the treatment of anal fistula have been introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Among them, the ligation of intersphincteric fistula tract procedure appears to be safe and effective and may be routinely considered for complex anal fistula. Another technique, the anal fistula plug, derived from porcine small intestinal submucosa, is safe but modestly effective in long-term follow-up, with success rates varying from 24%-88%. The failure rate may be due to its extrusion from the fistula tract. To obviate that, a new designed plug (GORE BioA®) was introduced, but long term data regarding its efficacy are scant. Fibrin glue showed poor and variable healing rate (14%-74%). FiLaC and video-assisted anal fistula treatment procedures, respectively using laser and electrode energy, are expensive and yet to be thoroughly assessed in clinical practise. Recently, a therapy using autologous adipose-derived stem cells has been described. Their properties of regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of this present article is to review the pertinent literature, describing the advantages and limitations of new sphincter-preserving techniques.
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                Author and article information

                Contributors
                0049-221 962030 , arne.wilhelm@ebzkoeln.de
                Journal
                Tech Coloproctol
                Tech Coloproctol
                Techniques in Coloproctology
                Springer International Publishing (Cham )
                1123-6337
                1128-045X
                7 March 2017
                7 March 2017
                2017
                : 21
                : 4
                : 269-276
                Affiliations
                [1 ]Center of Colorectal and Pelvic Floor Diseases, Aachener Str. 1006-12, 50858 Cologne, Germany
                [2 ]Competence Network of Chronic Venous Diseases, Kiel, Germany
                [3 ]ISNI 0000 0001 2153 9986, GRID grid.9764.c, Institute of Medical Informatics and Statistics, , Christian-Albrechts-University, ; Kiel, Germany
                Article
                1599
                10.1007/s10151-017-1599-7
                5423928
                28271331
                b25f73cd-cb0a-4ff5-9d68-bcb34434db0c
                © The Author(s) 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 17 November 2015
                : 16 September 2016
                Categories
                Original Article
                Custom metadata
                © Springer International Publishing AG 2017

                Gastroenterology & Hepatology
                anal fistula,repair,sphincter-preserving,laser,filac,faecal incontinence
                Gastroenterology & Hepatology
                anal fistula, repair, sphincter-preserving, laser, filac, faecal incontinence

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