Emerging Data on Fistula Laser Closure (FiLaC) for the Treatment of Perianal Fistulas; Patient Selection and Outcomes

Abstract

Fistula laser closure (FiLaC) is a relatively new sphincter-sparing technique in fistula surgery that was initially reported in 2011. It involves the radial dissipation of laser energy in the fistula tract and, through a combination of coagulation and shrinkage of the tract, is proposed to result in progressive sealing of fistulas. Early studies have suggested minimal impact on continence and touted the advantage of minimal morbidity with potential of repeat procedures if the technique fails initially. Despite early promising results, ten years on, questions remain on the technique, patient selection and long-term outcomes. This narrative review assesses the evidence reported to-date of radially emitting laser fistula surgery in the treatment of perianal fistulas.

Short term Outcomes of Fistula Laser Closure (FILAC) as a Sphincter Sparing Technique Versus Fistulotomy with Immediate Sphincter Reconstruction (FISR) in High Trans-Sphincteric Fistula–in-ano; a Prospective Cohort Study

“…22 In a narrative review of 14 articles, FiLaC is supposed to be feasible, safe, and easy to learn and is associated with minimal impairment of continence. 25 Those merits were confirmed in another study in condition that internal opening is closed and external opening is excised. 28 Despite carrying promising results, FiLaC has still some limitations in the form of difficulty of the probe to access side tracks or extensions, which has a negative impact on recurrence rates.…”

“…28 Despite carrying promising results, FiLaC has still some limitations in the form of difficulty of the probe to access side tracks or extensions, which has a negative impact on recurrence rates. 25 Success rates (Primary healing, mostly assessed clinically), varied from 20% (4/20 patients), 23 at a median follow-up of 10 months to 89% (24/27 patients) reported by Donmez et al at a median follow-up of 22 months. 24 In a recent retrospective study by Wolicki et al, healing rate of 74.70% after an observation period of 41.99 (± 21.59) months on average.…”

Anal fistulas are not all the same

“…If the number of tracts are not addressed prior to any minimally invasive surgery then it is unlikely the fistula will heal. In this study, the length of the fistula was directly associated with a reduced healing rate, but this argument is not always supported in the literature [2,3]. The use of procedures such as video-assisted fistula treatment (VAAFT) can have the benefit of downsizing the fistula tract and healing secondary tracts in a staged approach.…”

Fistula Laser Closure (FILAC)- Use of Radial Emitting Laser Probe

“…Coloproctologists now have an armamentarium of options, which includes the closure of the fistula tract with plugs, fibrin glue, or collagen paste without fistulotomy (i.e., laying open), advancement flaps, LIFT (ligation of the intersphincteric fistula tract), VAAFT (video-assisted anal fistula treatment) and laser ablation procedures. 3 Some new inventions such as the anal fistula plug or fibrin glue have not proven successful in the long term. 4,5 Since it was first described by Rojanasakul et al in 2006, LIFT gained popularity due to its high success rate and preservation of continence.…”

“…The internal opening was closed with sutures or with a combination advancement flap and sutures in few studies but in the majority of studies internal opening was not closed. 3 Few complications were reported following laser treatment Giamundo et al 9…”