Radially Emitting Diode Laser Closure of Transsphincteric Fistula-in-Ano

Background: There has been a shift in the treatment of fistula-in-ano towards a focus on preservation of continence while simultaneously eradicating disease. Utilization of radially emitting diode laser catheters to ablate fistula tracks has been described since 2011 with heterogenous studies publishing success rates ranging from 20% to 89%.

Objective: Present our experience managing solitary transsphincteric fistulas of cryptoglandular origin with radially emitting diode laser.

Design: Prospective non-randomized single center trial with 12-month follow-up.

Settings: Quaternary referral academic healthcare center.

Patients: Forty-six adults with transsphincteric fistula-in-ano.

Interventions: All underwent radially emitting diode laser closure of fistula-in-ano.

Main outcome measures: Clinical healing and fistula recurrence.

Results: Forty-six patients with a median age of 48 years (range, 26-85) underwent diode laser closure. Most were men (n = 28/60%). Twenty-four (52%) had previous fistula repairs with a median of 1.5 (range, 1-7) repairs per patient. All were followed for 12 months. Successful closure following one laser treatment occurred in 43%. Thirteen of 26 failures (50%) were able to undergo a delayed fistulotomy secondary to an anatomic change with the fistula becoming more superficial moving out of internal sphincter muscle following laser ablation, all of which healed. No patients experienced new or worsening (preexisting) fecal incontinence. Two (8%) continued treatment for abscesses / fistula branching. One (3%) experienced migration of the fistula from the base of the left labia to the introitus of the vagina and 1 experienced recurrence and worsening of their disease process with subsequent involvement of the coccyx (previous deep postanal space abscess).

Limitations: Limitations to our study include its non-randomized prospective nature, single center and surgeon experience, and small patient sample size.

Conclusions: Radially emitting diode laser closure is a continence preserving option to consider when treating transsphincteric fistula-in-ano. When the procedure fails it does not fail poorly (open wounds, retracted flaps, incontinence, etc.), and can be repeated. Complications can include abscess formation and fistula migration to adjacent anatomic locations (vagina). Even if not successful, following treatment the fistula can anatomically migrate distally becoming more superficial and thus providing the opportunity to proceed with a delayed fistulotomy. See Video Abstract.