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Review, VAAFT Article by Miniero & Mori

Review of article on VAAFT by,

P. Meinero  and L. Mori

Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas Tech Coloproctol. 2011 December; 15(4): 417–422

 

The article Video assisted anal fistula treatment (VAAFT) “a novel sphincter saving procedure for treating complex anal fistula” published in the issue of December 2011, in the Journal “Techniques in coloproctology”.  We (me and my associate form Indian Society of Coloproctology) read the article with keen interest. It is a new technique to visualize the interior of fistula and treat it through endoscopy. I congratulate both of you for propagating new concept.  We would like to learn the procedure. We had certain queries. On internet only your experimental article is available as literature on Vaaft as a guide.

The article had included patients operated up to May 2011 and paper was received for probable publication on August 2011, which suggests that in few cases there was no waiting period for healing of the fistula (2-3 months) & no follow up too. Ninety-eight out of these 136 patients were followed up for a minimum of 6 months. In first two/ three months 72 (52.9%) out of 136 cases were healed and 64 (47%) cases did not heal.  Sixty-two patients were followed up for at least 12 months, where 54 (39.7%) have primarily healed their fistula and about 84 (61.7%) patients there was no information to you. There is confusion and ambiguity about result which is the problematic aspect of the paper.

Every fistula has different structure and pattern of tracts. The abscess developed from cryptoglandular tissue into insterssphincteric space. Pus traverses through cylindrical & semi cylindrical spaces around anal canal &the rectum. The anal glands are situated more in number in the posterior aspect of the dentate line. Fistula is commonly adapting the shape of the spaces around the anus & rectum forms tract according; which is most commonly curvier. The pus flows in the direction away from the internal opening and tracts develop are in same directions.

Instrument

The fistuloscope of Vaaft is straight & rigid, can negotiate easily in straight fistula. The fistulae in the lower ½ of the perineum and away from the anal verge are curvier and multidirectional. For the straight and rigid scope it is difficult to negotiate them. In my experience of 9 years using straight & rigid cystoscope for fistuloscopy, it stops at the acute curves and impossible to insert further. Usually a fresh opening at acute curve helps to negotiate tract further. The new opening converts acute in to less curved or straight tract.

The external opening skin is adherent due to infection, fibrosis & chronicity still scope can be negotiated but snuggly fits into opening. It causes difficulty in flowing of irrigation fluid.  The fistula tracts are semi rigid tubes fixed due to infection & surrounded by fibrosis & they are not elastic one. Anaesthesia can relax the muscle tissue but not connective tissue like fat, fibrous and skin. It is difficult to understand that how by up & down and side to side movements can negotiate sharp curves and tortuous tracts, through fixed external opening at one end. In the article not a single case was abandoned due to failure to negotiate tract.

The Vaaft fistuloscope has 8 degree optic, is good for straight & forward view. In a distended fistula it is possible to view branches in the forward direction. But it is impossible to locate the branches having 90 degree or larger angle and in the backward direction to the insertion of scope. In fistula secondary branches are in direction away from internal opening. Some optical view is also blocked by the obturater at base. The optics of fistuloscope is of 1-1.5 m. m. in size which has limited field of vision, it will get lost in the bigger cavity and wide fistula. Such one m. m. optic fiber gives tuff time to visualize even in the urethra. In the small optical view correlation and orientation is difficult. The cystoscope has 4 m. m. optics of 30 degree view which gives very good and wide and side vision. In case of no internal opening irrigation fluid will not flow in to tract and vision will be poor. In results noted in your article out of 136 cases of complex fistula only in 7.2 % second tracts are found. In variably there are two or more tracts commonly found with cystoscope.

Treatment by Radiofrequency:-

Vaaft treats fistula by fulguration of the infected epithelial lining and burnt tissue is extracted by brush & washing it. The radiofrequency implemented for fulguration under water is very high energy. It is possible to penetrate at least 2-3 mm. of wall of fistula tract. The radiofrequency achieves tissue destruction by two methods: electric current or spark and secondly by producing heat. This heat production is uncontrolled and a lateral spread of this heat also destroys normal tissue unseen on gross examination. This leads to a larger area of tissue damage than intended (1, 2)

The penetration of heat will cause more necroses and detachment of slough later on, in a week or two. The treated fistula tract is kept open for drainage but no process is provided for the clearance of the sloughed material after 1 – 2 weeks.

The tract keeps on discharging for 2 – 3 months. In the series of 136 cases, 72 cases healed primary. In the wound kept open for healing cannot be called as primary healing.  It is beyond understanding that how the fistula with external opening of 4/5 m. m. remained open after a week and why it heals after 3 months as it becomes chronic. The debris from the blind secondary branches has no scope to discharge of the necrotic material developed later on.  It is difficult to negotiate cattery point into side branches. The discharge will collect inside the tract and form an abscess. Primary healing was achieved in72 patients out of 136 cases in 2-3 months. There is nothing suggestive about dressing or irrigation of wound. Whether repeated cleaning or abscess opening was required? There is no specific parameter defined, that after how many days if discharge continues, it will be called recurrence of fistula.

Irrigation fluid is used under pressure to distend semi rigid fistula tracts which can burst & create edema of the perineal region and carry infection from infected fistula to healthy soft tissue. Sitz bath is not given more than 15 minutes as tissue absorbs water. The procedure may require longer time.

As scope reaches to intersphincteric space the light glow will be visualizes through the rectal wall but tract may continue in the same space up or down & sideways. Only seeing light of scope cannot guide to locate internal opening of fistula. Internal opening is not the end of fistula in some cases.

Use of cynoacrilate will cause double trouble, acts as foreign body and gives pricking sensation. The harden cynoacrilate usually expelled as foreign body.

The stapling of internal opening by creating volcano is difficult as there was no dissection of mucosa underneath was done and more mucosa (2 Cm) is excised due to pull of stitches and stapler; it will create tension on staples and likely dehiscence.  The cynoacrilate used in 9 recurrent cases of your series, all had recurred again. Still will you like to use it as support to staple line

In the series, 7 recurrent fistulae patient’s had colostomy. We are surprised that colostomy is so commonly used in Italy for the fistula. In the Huge country like India have large number of patients of fistula; where, colostomy for fistula is not done so commonly.

In the series 136 cases were operated but detail study, about age & sex incidence, details about pre operative & operative findings were given of 98 cases only. It indicates that it is retrospective study of selected cases. There is no value for such study in the assess merit of experimental innovative procedure. There is no explanation why 38 cases were excluded from the series. Whether there was technical failure or any criteria for exclusion of these cases should have been explained by you.

The healing occurred in 72 (52.9 %) from 136 cases after 2 -3 months. In the remaining 64 (47%) cases no healing was observed or no information was available.  At the end of 12 months only 62 patients were followed and 54 were healed. It is not clear that from the same healed 72 patients were followed or any patients after 12 months. There was 26 cases had initial recurrence which were treated by vaaft. Out of 19 cases only 9 (47.3) cases were healed and 10(52.6% )cases had recurrence.

The patients lost to follow up were increasing in number, in first 6 months 38 (27.9%), after one year 84(61.7%) cases. Paper reaches to conclusion that 54(39.7%) fistulae healed out of 136 cases & there is no information about 84 cases (61.7%). About the achievement of the procedure you are innocent in 61.7% cases. In the era of extensive and wide communication, it is not acceptable 61.7% cases are lost to follow up. The exclusive instrument only for complex fistula is at least 5 times more costly than that of cystoscope. The cystoscpe can be useful in general, urology & gynecology surgery too. The vaaft technique derived particularly for complex fistula, are hardly 10-15 % of all fistula. For the treatment of simple fistula there are simple ways to treat like dilatation & curettage or lay open.

The specific instrument of high cost with unpredictable initial experimental result has to wait, before it makes any impression in the treatment of fistula.

We are interested in the procedure kindly explain, how we should proceed further to learn avoiding drawbacks of the instruments.

We will be grateful to you.

Your

Dr. S. D. Chivate & colleagues.

Reference

  1. Hainer BL, "Fundamentals of electrosurgery", Journal of the American Board of Family Practice, 4(6):419-26, 1991 Nov-Dec.
  2. Bruchier G, “The fundamentals of electro-surgery. High frequency current generators” CahProthese, 1980 Jan: 8 (29);95-106.