Treatment of perianal fistulas with ND:YAG laser--results in twenty cases

Comprehensive literature review of the applications of surgical laser in benign anal conditions

Surgery for benign anal conditions is a common practice and is usually followed by a good outcome. The present review aimed to summarize the emergence and evolution of different laser techniques used for the treatment of benign anal conditions and report their current outcome. PubMed and Scopus were searched for studies that assessed the use of laser in benign anal conditions. Anal conditions reviewed were hemorrhoids, anal fistula, anal warts, anal stenosis, and anal fissure. The full text of the studies retrieved was summarized in a narrative and tabular form. Laser techniques used for the treatment of hemorrhoidal disease were laser open hemorrhoidectomy, laser hemorrhoidoplasty, and Doppler-guided hemorrhoidal laser dearterialization. Resolution of hemorrhoidal symptoms was reported in 72-100% of patients after laser treatment. YAG laser, fistula laser closure, and photodynamic therapy have been used for the treatment of anal fistula with success rates ranging from 20 to 92.6%. Anal warts can be treated with photodynamic therapy with or without YAG or CO² laser with a success rate up to 88%. A few studies reported the use of laser in the treatment of chronic anal fissure and anal stenosis. The use of laser in the treatment of benign anal conditions is associated with promising outcomes. Laser was most assessed in hemorrhoidal disease and anal fistula and showed more consistent success rates with hemorrhoidal disease than with anal fistula. Preliminary reports assessed the outcome of laser treatment in other conditions as anal fissure and warts with acceptable outcomes.

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

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.

Fistula-tract Laser Closure (FiLaC™) for complex urethroperineal fistula

BACKGROUND

Fistula formation in hidradenitis suppurativa follows an uncontrolled infection with subcutaneous tracts leading to 'watering-can' or 'pus-pot' perineum. Closure of this type of fistula implies major surgery and is bound to fail in refractory inflammatory environment. Minimally invasive techniques have become the first line of choice in every type of surgery.

METHODS

Fistula-tract Laser Closure (FiLaC™, Biolitec, Germany) is a novel technique already reported to have been used in the treatment of fistula-in-ano and pilonidal sinus. It consists of blind cauterization and obliteration of the fistula tract from the inside by means of a radial-emitting laser probe. We present two patients who underwent surgery for urethroperineal fistula using this technique.

RESULTS

In both cases, the fistula tracts were completely closed after 3 months of follow-up. The wounds had healed smoothly and complete resolution of symptoms was noted.

CONCLUSIONS

The use of FiLaC™ for the treatment of urethroperineal fistula is feasible and safe. The minimally invasive nature of the technique and limited postoperative pain permit daycare surgery.

Laser ablation of fistula tract: a sphincter-preserving method for treating fistula-in-ano

BACKGROUND

Lasers are used to treat various types of diseases, including fistula-in-ano. Until recently, the lasers used for this procedure radiated linear energy.

OBJECTIVE

To assess the short-term outcomes of patients undergoing ablation of fistula in-ano tract using a new laser that radiates circumferential energy.

DESIGN & SETTING

This study was approved by the local ethics committee at our institution. A 15-watt laser probe emitting at a wavelength of 1470 nm and producing 100-120 joules/cm of energy, was applied to 50 patients with fistula-in-ano under general anesthesia. Short-term outcomes, including success rate, complications, pain scores and time to return to normal daily activities, were evaluated. Success was defined as cessation of either the discharge or the patient's complaints.

RESULTS

Thirty-seven male and 13 female patients with a median age of 41 years (range: 23-83 years) were treated on an outpatient basis. Among these patients, 10 had inter-sphincteric fistulas, 34 had low transsphinteric fistulas and 6 had high transsphinteric fistulas. None of the patients required parenteral analgesics. The return to daily activities required a median of 7 days (range: 5-17 days). The median follow-up period was 12 months (range: 2-18 months). The success rate was 82%. Patients for whom the laser treatment was unsuccessful were later treated using traditional surgical methods.

LIMITATIONS

The retrospective review of the data and the fact that substantial follow-up was done by phone and not through physical examination are the main limiting factors in this study.

CONCLUSION

Laser ablation of fistula tract is a safe, effective, sphincter-preserving therapy that can be successfully performed by surgeons.

Long-Term Evaluation of Canine Perianal Fistula Disease Treated With Exclusive Fish and Potato Diet and Surgical Excision

The records of 33 dogs that had perianal fistula disease treated with en bloc surgical excision and bilateral anal saculectomy, and that were perioperatively administered an exclusive white fish and potato diet, were reviewed to determine outcome. By 1 year after surgery, 87.9% of the dogs had complete or near-complete resolution of visible fistula disease, while only 20.7% continued to have mild intermittent clinical signs. Fecal incontinence was not reported in any dog. Overall, complications were considerably less in both severity and frequency when compared with previous reports.

Preoperative Immunosuppressive Therapy and Surgery as a Treatment for Anal Furunculosis

OBJECTIVES

To evaluate the efficacy of combining preoperative immunosuppressive therapy with surgical excision for treatment of anal furunculosis (AF) in dogs.

STUDY DESIGN

Retrospective study.

ANIMALS

Dogs (n=25) with stages 1-4 AF.

METHODS

Preoperative immunosuppressive therapy was either cyclosporine A (CyA) alone or in combination with ketoconazole (Group 1; n=18), or azathioprine combined with prednisolone (Group 2; n=7). Surgical excision of residual draining tracts, cryptectomy, and anal sacculectomy were performed. Only dogs with postoperative clinical follow-up exceeding 9 months were retained for the study.

RESULTS

Both immunosuppressive protocols were effective in reducing progression of AF. Subsequent draining tracts excision, cryptectomy, and anal sacculectomy were bilateral (12 dogs) or unilateral (13 dogs of which 4 had bilateral anal sacculectomy). Postoperative recovery was uneventful, except for 2 dogs that had wound breakdown. Recurrence was not observed in any of the dogs that had bilateral surgical excision and or in 9 dogs that had unilateral excision.

CONCLUSION

Preoperative immunosuppressive therapy, combined with bilateral surgical resection of affected tissue consistently, resulted in resolution of AF. Four dogs that had recurrence had unilateral excision despite initial bilateral involvement, suggesting that all diseased tissue should be excised.

CLINICAL RELEVANCE

These preliminary results suggest that immunosuppressive therapy before surgical excision for AF yields minimizes recurrence in dogs.

Tail and Perineal Wounds

Tail and perineal wounds arise from various causes. Reconstructive techniques are beneficial to the resolution of congenital, traumatic, and neoplastic conditions that involve the tail and perineum. This article reviews some common and not so common conditions and the techniques to treat them effectively.

The role of surgery in the management of canine anal furunculosis. A review of the literature and a retrospective evaluation of treatment by surgical resection in 51 dogs

AIMS

To retrospectively evaluate the outcome of surgical management of anal furunculosis (AF) in 51 dogs. To compare the outcome of surgery with those of current medical protocols by way of a review of the literature.

METHODS

Dogs referred for treatment of AF (n=51) were treated by en bloc surgical resection of diseased tissue and primary wound closure. This technique was combined with bilateral anal sacculectomy in all cases in which the anal sacs had not been previously removed. Immunomodulatory therapies were not used, with the exception of post-operative metronidazole antibiosis for 7-10 days. Follow-up was performed by the author using a telephone questionnaire.

RESULTS

Forty-eight dogs were eligible for post-operative follow-up 1.5 to 36 (mean 17.4, median 18) months after surgery. Lesion recurrence, faecal incontinence and stricture formation occurred in 2%, 4% and 13% of dogs, respectively. The percentage of dogs considered by their owners to have an acceptable level of faecal continence and an improved quality of life was 94%.

CONCLUSIONS AND CLINICAL RELEVANCE

The aetiopathogenesis of canine AF remains unclear. Whilst recent advances in medical management by the use of various immunomodulatory medications (such as cyclosporine) hold promise, this approach has yet to be refined with respect to affordability, long-term efficacy and morbidity. With meticulous surgical dissection and reconstruction techniques (anoplasty), excellent success rates can be achieved following a single surgical procedure with minimal complications. Surgery remains a viable treatment option, alone or in combination with immunomodulatory medications, until a more thorough understanding of this debilitating disease is achieved.

Efficacy of combined cyclosporine A and ketoconazole treatment of anal furunculosis

Cyclosporine A and ketoconazole were used as a combined therapy to treat 19 dogs with anal furunculosis. Complete resolution of all lesions was achieved in three to 10 weeks, but recurrences occurred in seven of the 19 dogs (36.8 per cent), with remission periods extending from one to six months for these dogs. Adverse effects of treatment included excessive hair loss, intermittent lethargy, vomiting and decreased appetite in some dogs, but none of the signs were considered serious. The results of treatment are comparable with, if not better than, the surgical alternatives. There is an approximate 70 per cent cost saving over the use of cyclosporine alone.

Lasers in veterinary medicine--where have we been, and where are we going?

Future use of lasers in medicine depends on the active participation of veterinarians in the inception and development of new devices that meet the needs of the entire medical profession. The sensible clinical approach that must be taken every day in the practice of veterinary medicine equips the veterinarian with a unique ability to understand the practical applications of biomedical lasers. Veterinary medicine can and should be in the forefront during these exciting times, adding an essential dimension to development of this twenty-first century technology.

Use of the carbon dioxide laser for perianal and rectal surgery

The skin of the perianal region is very thin and sensitive. The carbon dioxide laser is a very effective tool for removing tumors and treating conditions of this area. It offers a "no touch" method of treatment for conditions of the perianal region. There is less bleeding, less pain, less swelling with the use of the carbon dioxide laser. The carbon dioxide laser is an effective tool for excising perianal tumors, rectal tumors, performing anal sacculectomies and treating perianal fistulas.

Cyclosporin and ketoconazole interaction for treatment of perianal fistulas in the dog

OBJECTIVE

To assess the use of concurrent ketoconazole and low dose cyclosporin administration in a group of dogs with clinical evidence of perianal fistulas, and to determine if this combination could be used to manage perianal fistulas effectively.

DESIGN

Prospective clinical trial

PROCEDURE

Sixteen dogs with clinical evidence of perianal fistulas were given ketoconazole (10 mg/kg once daily) and cyclosporin (1 mg/kg twice daily initially) for 16 weeks. Blood cyclosporin assays were performed regularly and cyclosporin doses were altered to achieve a stable blood level above 200 ng/mL. Regular examinations assessed the dogs' general health, changes in clinical behaviour, fistula size and number. A complete blood count and serum biochemical analysis was performed in all dogs before and after the treatment period, and after 8 weeks of treatment in 12 dogs. Dogs were assessed for recurrence of lesions at 1, 3 and 12 months after the trial.

RESULTS

All dogs showed marked improvement in lesions and behaviour within 14 days of the medication. Fourteen dogs completed the trial. Two dogs were excluded due to concurrent disease. Thirteen dogs (93%) showed complete resolution of fistulas during the treatment period. Seven dogs (50%) had no recurrence after 12 months. Recurrence was seen in three dogs (21%) at 8, 10 and 12 months after treatment, and in three dogs (21%) within 1 month of treatment. The medication was well tolerated. Side effects included transient anorexia, vomiting and lethargy in some dogs, increased shedding of hair and gingival hyperplasia. Ketoconazole administration allowed a dramatic reduction in cyclosporin dose (over 90% in 12 dogs and 80% in the other two) compared to previously reported cases treated with cyclosporin alone.

CONCLUSION

The use of combined ketoconazole and cyclosporin provided an effective treatment for perianal fistulas. Outcomes were similar to those seen with cyclosporin alone, but allowed a significant reduction in cyclosporin dose and, therefore, cost. The use of immunosuppressive therapy in the treatment of perianal fistulas was effective and avoided many of the problems associated with surgical treament.

Cyclosporine and ketoconazole for the treatment of perianal fistulas in dogs

OBJECTIVE

To evaluate efficacy and cost of using cyclosporine and ketoconazole for the treatment of perianal fistulas in dogs.

DESIGN

Clinical trial.

ANIMALS

12 dogs with perianal fistulas.

PROCEDURE

Dogs received cyclosporine and ketoconazole orally (target whole blood trough cyclosporine concentrations of 400 to 600 ng/ml). Study endpoints were resolution of clinical signs, remission, and recurrence of disease. Adverse effects and cost of medications were reported. Results were compared with those from previous studies in humans and in dogs in which single agent cyclosporine treatment for perianal fistulas was used.

RESULTS

All dogs had resolution of clinical signs. Eight dogs went into remission; however, 5 of those 8 had recurrence of fistulas. Adverse effects of treatment were minimal and well tolerated. Cost of treatment was comparable to traditional surgical options and less than single agent cyclosporine treatment.

CONCLUSIONS AND CLINICAL RELEVANCE

Administration of cyclosporine with ketoconazole is an effective and cost-comparable treatment for perianal fistulas in dogs.

Association between anal furunculosis and colitis in the dog: preliminary observations

Treatment of anal furunculosis in dogs is often unsatisfactory and may be associated with significant recurrence and complications. This may be compounded by the simultaneous presence of colitis in affected animals. Clinical signs associated with colitis and anal furunculosis may be similar, including faecal tenesmus, dyschezia and haematochezia. To examine the incidence of concurrent anal furunculosis and colitis, colonic biopsies were collected from 18 dogs referred for treatment of anal furunculosis. Nine dogs (50 per cent) had a histopathological diagnosis of colitis. Clinical signs more indicative of colitis than anal furunculosis (increased frequency of defecation, mucus in faeces and diarrhoea) were not observed more frequently in dogs with confirmed colitis compared with those with furunculosis alone. Therefore, while an association between colitis and anal furunculosis may exist, clinical signs alone cannot be used as an indicator of the presence of colitis in cases of anal furunculosis. The authors recommend that colonic biopsies should be undertaken in all dogs presented with anal furunculosis. Whether specific treatment of colitis in dogs with histopathological evidence of colitis improves the outcome of treatment for anal furunculosis awaits further study.

Cyclosporin as the sole treatment for anal furunculosis: preliminary results

Cyclosporin was used, as the sole agent, to treat six cases of anal furunculosis, allowing the clinical response to the drug to be evaluated. The initial dose was 7.5 mg/kg twice a day. Following one week of treatment, whole blood cyclosporin trough levels were measured and the dose was adjusted to obtain a stable trough level of 400 to 600 ng/ml. In all dogs, the lesions were found to follow a similar pattern of resolution throughout the course of treatment. The presenting signs disappeared within one week of treatment, with a reduction in lesion size of 50 to 90 per cent. Lesions then gradually healed over the remainder of the treatment, which lasted from 10 to 20 weeks. One case required cryosurgical treatment to resolve a 2 mm diameter persistent ulcerated lesion following 18 weeks of treatment. The length of follow-up was four to 14 months (mean 7.7 months). One case developed recurrence of the lesions eight weeks post-treatment.