Anal Sphincter Preserving Fistula Laser Closure FiLaCTM: First Study in Iraq

Perianal fistulas, and specifically high perianal fistulas, remain a surgical treatment challenge. Many techniques have, and still are, being developed to improve outcome after surgery. The ideal surgical treatment for anal fistula should eradicate sepsis and promote healing of the tract, whilst preserving the sphincters and the mechanism of continence. This novel sphincter-saving technique uses an emitting laser probe [Fistula laser closure (FiLaCTM), Biolitec, Germany], which destroys the fistula epithelium and simultaneously obliterates the remaining fistula tract. Since the main reason for surgical failure is a persistent fistula tract or remnants of fistula epithelium which were not excised, it was postulated that the benefit of this newly designed radial-emitting laser probe was to eliminate fistula epithelium or any granulation tissue in a circular manner and then, to obliterate the fistula tract by a shrinkage effect. This is the first pilot Iraqi study which presents the outcome of FiLaCTM in the management of high and recurrent anal fistulae. The study conducted in a single hospital, by a single trained general and GIT surgeon (NA). All patients were preoperatively assessed for history of presentation, clinical examination, ano-proctoscopy, and MRI of the perineum to assess the dimensions and relations of the fistulous tract to the anal sphincter complex and Levatorani muscle. All patient subjected to 2 staged operation: First stage is drainage, staining with methylene blue of fistula tract and probing under general or epidural anesthesia, and insertion of 2-mm latex vessel loop (Ethiloop, Ethicon Products, Germany). Second stagestarted after 6 weeks when the tract length is little bit shorter and diameter of the fistula tract is 5mm and less, with no abscesses. The internal opening is closed with 2/0 vicryl©. The laser probe was inserted through the perineal fistula opening using a “Leonardo DUAL 45©”) diode laser (Biolitec AG, Germany), and the fistulae tracts subjected to laser energy millimeter by millimeter in the aim of elastin melting and ablation. Patients discharged same day with follow up schedule for 1-2 year. All 72 patients were male, one female with ano-vaginal fistula has been excluded from the study. Median age 37 years; range 19-56 years. Follow-up period 3-24 months. FiLaCTM started for the first time in May 2018, and the patients are still under follow up. Forty seven patients 47 (65.2%) were previously subjected to anal surgery, either abscess drainage, fistulectomy, or fistulotomy, no one has been subjected to Laser, Flap, Plug or LIFT surgery. One patient came with first stage abscess drainage and seton placement. Majority, 52 patients ( 72.2%) were trans--sphincteric, 12 patients’ ( 16.6%) inter--sphincteric, 6 patient (8.3%) supra--sphincteric and 2 patients (2.7%) were extra--sphincteric. The median operation time was 18 (10-32) min. Primary healing observed after the first application of FiLaCTM In 43 patients (59.7%), from these; 39 patients ( 54.1%)of total patients has pass 12 months follow up and certified as permanently healed, still 4 cases waiting final healing announcement which represent 5.5% added success. We have 10 (13.8%) patients subjected to FiLaCTM in the last 3 months and under follow up 8 (11.1%) promises healing, this will make success rate cases to 51 (70.8%). Patient who are considered failed to heal and needs further application of laser or switch to other modality of treatment were 21(29.1%) Up to 30% of fistulas persist after surgery despite many improvements in surgical skills and technique. One major reason for surgical failure is a persistent fistula track or remnants of the fistula epithelium which could not be removed during surgery, Wilhem A. The FiLaCTM procedure is performed in our study in 2 states with the aim of improving the healing and raising the success rate. Even we have a short experience with the FiLaCTM procedure; we found it to combines the ability to treat complicated and simple fistulae with high success rate, with no compromise to the anal sphincter continence. As a pilot study, the above conclusion looks acceptable but, a longer follow up and a larger cohort study needed in future.