Minimally invasive video-assisted sphincter-sparing treatment of complex rectal fistulas using the VAAFT technique

Background. Video-assisted anal fistula treatment (VAAFT) is a new minimally invasive sphincter-sparing technology.

Objective: to describe technical characteristics of VAAFT and evaluate short-term outcomes.

Materials and methods. We used a specialized surgical video system (VAAFT®; Karl Storz) for the treatment of complex high rectal fistulas. This technology allows a surgeon to use a special fistuloscope to perform visual examination of the fistula, find its internal opening, and detect secondary fistula passages and inflows. In addition to visual inspection, it is possible to simultaneously conduct a cytological brush through the working channel of the endoscope in order to clear the fistula from detritus and desquamate lining mucosa, and then perform fistula ablation using a monopolar electrode. The internal opening of the fistula can be either closed by a flap or sutured using a linear stapling device or closed using an endoscopic clip with additional sealing of the suture line with biological glue.

Results. Between September 2017 and August 2019, a total of 112 patients underwent VAAFT® surgeries. Ninety-three patients (83 %) were followed up for 6 months postoperatively. We observed no significant complications during the follow-up period. The majority of study participants (85 %) did not experience severe pain (>2–4 points on a visual-analog scale) in the early postoperative period. Primary healing was achieved in 98 patients (87.5 %) within 2–3 months. Eighty-nine individuals (79.5 %) were followed up for more than 1 year. Rectal fistula healing within 1 year after VAAFT® surgery was observed in 82 % of patients.

Conclusions. The main advantage of the VAAFT® technique is the combination of the diagnostic stage for fistula visualization and identification of the internal opening with the possibility of simultaneous surgical treatment.

1. Garcia-Aguilar J., Belmonte C., Wong W.D. et al. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum 1996;39:723–9. DOI: 10.1007/BF02054434.

2. Sangwan Y.P., Rosen L., Riether R.D. et al. Is simple fistula-in-ano simple? Dis Colon Rectum 1994;37:885–9. DOI: 10.1007/BF02052593.

3. Ritchie R.D., Sackier J.M., Hodde J.P. Incontinence rates after cutting seton treatment for anal fistula. Colorectal Dis 2009;11:564–71. DOI: 10.1111/j.1463-1318.2008.01713.x.

4. Atkin G.K., Martins J., Tozer P. et al. For many high anal fistulas, lay open is still a good option. Tech Coloproctol 2011;15:143–50. DOI: 10.1007/s10151-011-0676-6.

5. Rojanasakul A. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol 2009;13:237–40. DOI: 10.1007/s10151-009-0522-2.

6. Lupinacci R.M., Vallet C., Parc Y. et al. Treatment of fistula-in-ano with the Surgisis AFP TM anal fistula plug. Gastroenterol Clin Biol 2010;34:549–53. DOI: 10.1016/j.gcb.2009.06.021.

7. Cirocchi R., Santoro A., Trastulli S. et al. Meta-analysis of fibrin glue versus surgery for treatment of fistula-in-ano. Ann Ital Chir 2010;81:349–56.

8. Parks A.G., Stitz R.W. The treatment of high fistula-in-ano. Dis Colon Rectum 1976;19:487–99. DOI: 10.1007/BF02590941.

9. Parks A.G., Gordon P.H., Hardcastle J.D. A classification of fistula-in-ano. Br J Surg1976;63:1–12. DOI: 10.1002/bjs.1800630102.

10. Aguilar P.S., Plasencia G., Hardy T.G.Jr. et al. Mucosal advancement in the treatment of anal fistula. Dis Colon Rectum 91985;28:496–8. DOI: 10.1007/BF02554093.

11. Ozuner G., Hull T.L., Cartmill J., Fazio V.W. Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum 1996;39:10–4. DOI: 10.1007/BF02048261.

12. Schouten W.R., Zimmermann D.D., Briel J.W. Transanal advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 1999;42:1419–23. DOI: 10.1007/BF02235039.

13. Mizrahi N., Wexner S.D., Zmora O. et al. Endorectal advancement flap: are there predictors of failure? Dis Colon Rectum 2002;45:1616–21. DOI: 10.1097/01.DCR.0000037654.01119.CD.

14. Sonoda T., Hull T., Piedmonte M.R., Fazio V.W. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum 2002;45:1622–8. DOI: 10.1007/s10350-004-7249-y.

15. Sentovich S.M. Fibrin glue for all anal fistulas. J Gastrointest Surg 2001;5:158–61. DOI: 10.1016/s1091-255x(01)80028-7.

16. Buchanan G.N., Bartram C.I., Phillips R.K.S. et al. Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial. Dis Colon Rectum 2003;46:1167–74. DOI: 10.1007/s10350-004-6708-9.

17. Sentovich S.M. Fibrin glue for anal fistulas: long-term results. Dis Colon Rectum 2003;46:498–502. DOI: 10.1007/s10350-004-6589-y.

18. Gisbertz S.S., Sosef M.N., Festen S. et al. Treatment of fistulas in ano with fibrin glue. Dig Surg 2005;22:91–4. DOI: 10.1159/000085299.

19. Ellis C.N., Clark S. Fibrin glue as an adjunct to flap repair of anal fistulas: a randomized, controlled study. Dis Colon Rectum 2996;49:1736–40. DOI: 10.1007/s10350-006-0718-8.

20. Williams J.G., Farrands P.A., Williams A.B. et al. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 2007;9:18–50. DOI: 10.1111/j.1463-1318.2007.01372.x.

21. Adamina M., Hoch J.S., Burnstein M.J. To plug or not to plug: a cost-effectiveness analysis for complex anal fistula. Surgery 2010;147:72–8.

22. Johnson E.K., Gaw J.U., Armstrong D.N. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum 2006;49:371–6. DOI: 10.1007/s10350-005-0288-1.

23. Christoforidis D., Etzioni D.A., Goldberg S.M. et al. Treatment of complex anal fistulas with the collagen fistula plug. Dis Colon Rectum 2008;51:1482–7. DOI: 10.1007/s10350-008-9374-5.

24. Lawes D.A., Efron J.E., Abbas M. et al. Early experience with the bioabsorbable anal fistula plug. World J Surg 2008;32: 1157–9. DOI: 10.1007/s00268-008-9504-1.

25. Malik A.I., Nelson R.L. Surgical management of anal fistulae: a systematic review. Colorectal Dis 2008;10:420–30. DOI: 10.1111/j.1463-1318.2008.01483.x.

26. Wang J.Y., Garcia-Aguilar J., Sternberg J.A. et al. Treatment of transsphincteric anal fistulas: are fistula plugs an acceptable alternative? Dis Colon Rectum 2009;52: 692–7. DOI: 10.1007/DCR.0b013e31819d473f.

27. Rojanasakul A., Pattanaarun J., Sahakitrungruang C., Tantiphlachiva K. Total anal sphincter saving technique for fistulainano: the ligation of intersphinteric fistula tract. J Med Asso Thai 2007;90:581–6.

28. Shanwani A., Nor A.M., Amri N. Ligation of the intersphincteric fistula tract (LIFT): a sphincter-saving technique for fistula-inano. Dis Colon Rectum 2010;53:39–42. DOI: 10.1007/DCR.0b013e3181c160c4.

29. Bleier J.I., Moloo H., Goldberg S.M. Ligation of the intersphincteric fistula tract: an effective new technique for com plex fistulas. Dis Colon Rectum 2010;53:43–6. DOI: 10.1007/DCR.0b013e3181bb869f.

30. Lunniss P.J. LIFT procedure: a simplified technique for fistula-in-ano. Tech Coloproctol 2009;13:241–2. DOI: 10.1007/s10151-009-0523-1.

31. Athanasiadis S., Helmes C., Yazigi R., Kohler A. The direct closure of the internal fistula opening without advancement flap for transsphicteric fistulas-in-ano. Dis Colon Rectum 2004;47:1174–80. DOI: 10.1007/s10350-004-0551-x.

32. Thomson W.H., Fowler A.L. Direct appositional (no flap) closure of deep anal fistula. Colorectal Dis 2004;6:32–6. DOI: 10.1111/j.1463-1318.2004.00485.x.

33. Wilhelm A. New technique for anal fistula repair using a novel radial emitting laser probe (FILAC TM ). Tech Coloproctol 2011; 15:239. DOI: 10.1007/s10151-011-0726-0.

34. Ortiz H., Marzo M., De Miguel M. et al. Length of follow-up after fistulotomy and fistulectomy associated with endorectal ad vancement flap repair for fistula in ano. Br J Surg 2008;95:484–7. DOI: 10.1002/bjs.6023.