2. 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

3. SHADES OF FISTULA

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

5. Issues With Complex Fistula
Sphincter Damage
Recurrence
Multiple surgeries

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

7. Life Long Seton !!

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10. VAAFT

11. PICARLO MEINERIO The VAAFT Man
MENDRISO SWITZERLAND SEP 2013

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

13. 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

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

15. The Equipment

16. 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

17. 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

18. All Fistulae alike inside !!

19. Per-op

20. FISTULOSCOPY

21. Treatment Phase
Step1 Marking the Internal Opening

22. Removal of Debris Step 2

23. Electro-fulguration of Track Step 3

24. Closure of Internal Opening Step 4

25. Glue instillation Step 5

26. The Post-procedure

27. EIGHT WEEKS POST-VAAFT
Per-op Picture Case 1

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

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

30. Problems
Recurrent discharge
Early closure of track
Recurrence

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

32. Internal opening identified 36 cases

33. 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)

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

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

36. Multiple Fistulae Combined approach

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

38. Thanks