VAAFT IN THE MANAGEMENT OF COMPLEX PERI-ANAL FISTULA MOHAMMED AMIR FCPS, FRCSEd PROFESSOR OF SURGERY SHIFA TAMEER-E-MILLAT UNIVERSITY/SHIFA COLLEGE OF MEDICINE

SHADES OF FISTULA

Issues In Fistula management? The biggest issue: RECURENCE (7-65%) (van Koperen PJ et al, Dis Colon Rectum. 2008 Oct;51(10):1475-81 Stremitzer S et al, Colorectal Dis. 2010 Mar 11, )

Issues With Complex Fistula Sphincter Damage Recurrence Multiple surgeries

Options for Complex Fistula Setons Cutting Non-cutting LIFT Fibrin glue Fistula Plug VAAFT

Life Long Seton !!

Currenrt Trends in Manangment of Fistula-in-Ano: Can We ... www.emro.who.int/imemrf/J_Surg.../J_Surg_Pak_Int_2012_17_1_1.pdf by M Amir - ‎2011 - ‎Related articles of perianal fistula which is still widely used in current practice. Perianal fistula, like other benign anorectal ... incontinence and recurrence after surgical treatment.

VAAFT

PICARLO MEINERIO The VAAFT Man MENDRISO SWITZERLAND SEP 2013

Rationale Minimal Invasive Procedure with direct visualization of the fistula track/s

The Procedure of VAAFT Diagnostic Phase Treatment Phase Fistuloscopy Marking the internal opening Fulguration of fistulous track/s Curettage of debris Closure of internal opening Instillation of glue

VAAFT fistuloscope Optic channel Washing channel Operative channel Handle Sheath Optic channel Washing channel Operative channel Handle Sheath

The Equipment

The Equipment The Fistuloscope has an optical channel and a working and irrigation channel. Diameter 3.2 X 4.8 mm Operative length 18 cm A removable handle allows easier maneuvering. Two taps: one connected to a 5,000 ml bag of glycine–mannitol 1% solution. The second for suction

Two phases Diagnostic: External Opening widened via a small inscion around it Fistuloscope is advanced and directed inside to visualise the fistulous track and to identify any secondary tracks. Therapeutic: Different Steps

All Fistulae alike inside !!

Per-op

FISTULOSCOPY

Treatment Phase Step1 Marking the Internal Opening

Removal of Debris Step 2

Electro-fulguration of Track Step 3

Closure of Internal Opening Step 4

Glue instillation Step 5

The Post-procedure

EIGHT WEEKS POST-VAAFT Per-op Picture Case 1

Potential benefits Minimal invasive Minimal damage to internal sphincter Minimal dissection Minimal postoperative pain Healing

Difficulties View Fulguration Closure of internal opening Glue instillation Post-op

Problems Recurrent discharge Early closure of track Recurrence

Initial experience With VAAFT 40 cases 34 complex 6 midlevel Recurrent 10 Multiple 15 Ages: 16-44 years Male: 34 Female: 06

Internal opening identified 36 cases

Results Healed so far 34 (12-18 months) Redo surgery 2 (Seton 1, Fistulotomy 1) Still following 3 (4-6 Months) Lost to Follow up 1 (Afghanistan)

Follow up Minimum 6 months May continue till one year if still persistent !! Long term follow up needed

The Paradigm Shift Worry more about immediate morbidity/ies and less about recurrence i.e., Sphincter damage

Multiple Fistulae Combined approach

Time to Change……. Only time will TELL !!

Thanks