Anal Fistula Treatment: Laser (FiLaC) in Istanbul | Yasir Gozu MD

One cause of fistula formation is an abscess that fails to heal for a long time. If the abscess does not fully heal, the cavity that remains connected to the bowel can keep refilling with infection, which can prevent healing. Eventually, the abscess may grow toward the skin, another organ, or a body cavity, forming a fistula. Although various factors play a role in the development of fistulas, the most common causes are listed below:

• Rectovaginal fistulas can form between the vagina and the rectum as a result of severe vaginal tears during childbirth and infections of episiotomy incisions.
• Intestinal fistulas can develop after digestive system surgery or after radiotherapy used in cancer treatment.
• Chronic inflammatory bowel diseases such as Crohn's disease or ulcerative colitis, as well as certain sexually transmitted diseases, HIV, and tuberculosis, can also cause fistula formation.
• Cancer can pave the way for fistula formation through tissue destruction.
• Radiotherapy can lead to fistula formation during cancer treatment.
• Modern medical devices, such as catheters or endoscopes, can accidentally puncture the wall of an organ or vessel, causing inflamed wounds.
• Diverticulitis. Infections of the small pouch-like structures in the colon can lead to fistulas.
• Hidradenitis suppurativa. This chronic skin condition, which causes abscesses and scarring, can trigger fistula formation.
• Procedures such as rectal or hemorrhoid surgery can create complications involving fistula development around the anus.
• Surgeries such as hysterectomy and cesarean section can cause fistulas to form between the bladder and the vagina.
• Operations performed on the back wall of the vagina can open fistulas affecting the anus or rectum.

The symptoms of a fistula vary depending on where the abnormal connection is located. A perianal fistula can cause a constant feeling of pain or swelling in the anal area. A fistula between the intestine and the bladder can lead to recurrent urinary tract infections. Fistulas that form between two segments of the intestine may cause no symptoms at all. Fistula symptoms include pain, fever, tenderness, itching, pus, and foul-smelling discharge. These symptoms vary in proportion to the severity and location of the fistula.

Anal Fistula Symptoms

• Skin irritation around the anus
• A constant, throbbing pain around the anus that may worsen with sitting, moving, bowel movements, or coughing
• Foul-smelling discharge coming from around the anus
• Pus or blood during bowel movements
• Increased swelling, redness, and warmth around the anus when an abscess is present
• In some cases, difficulty controlling bowel movements

The opening of the fistula may be felt as a small hole in the skin around the anus, though it can be difficult for the patient to notice.

Fistulas are usually diagnosed based on the patient's symptoms and a physical examination. When necessary, imaging methods such as a CT scan, barium enema, colonoscopy, sigmoidoscopy, upper endoscopy, or fistulogram may be used.

In a fistulogram, a contrast agent is injected into the fistula and X-ray images are taken. The contrast agent makes the fistula appear more clearly on the film. For fistulas in the rectum, this procedure is performed using an enema-like method, while for fistulas opening onto the skin, a small tube is placed into the opening. X-rays are taken from different angles by changing the patient's position.

Anal fistulas cannot heal on their own. Believing otherwise causes patients to lose time and can allow their condition to worsen. In addition, it has been reported that in fistulas left untreated for a long time, the risk of cancer developing in the surrounding tissues may increase, although this is rare.

The primary treatment for fistulas is surgery. Antibiotic therapy plays only a supportive role and has no curative effect. Surgery involves opening and cleaning the long, inflamed channel known as the fistula tract. This procedure can also affect the anal sphincters; the degree of impact depends on the surgeon's experience and skill.

During the operation, with the patient under anesthesia, the anus is opened with a retractor, and hydrogen peroxide is applied through the fistula's external opening near the skin surface to confirm the location of the internal opening in the anus. The course of the fistula tract is mapped using a special metal wire called a stylet. The amount of muscle that will be affected after surgery is then estimated, and the operation is performed.

If the Fistula Is Simple

• Fistulotomy (laying open the tract) is the standard method for simple, superficial fistulas.

If the Fistula Is Complex

• Seton placement,
• Sphincter-sparing methods such as a mucosal advancement flap may be used.

Laser Treatment

Beyond conventional surgery, non-surgical treatment options are also available today. The leading non-surgical method is laser treatment, which acts directly on the fistula site. The laser method, which has recently become widely used in anal fistula treatment, preserves the muscles and increases patient comfort. In non-surgical laser treatment, a fine-tipped radial fiber is inserted into the fistula, and controlled laser energy is applied to the fistula channel inside the anus. This aims to close the fistula wall along the channel. In suitable patients the fistula can heal with this method; some may need a repeat procedure. If an abscess is present, it is drained while the rectal muscles are preserved. In suitable patients, this treatment method allows a quicker return to daily life.

• Laser treatment stands out as a comfortable and fast treatment option!
• Patients undergo this treatment under local anesthesia, without the need for general anesthesia.
• After the procedure, an appropriate diet may be recommended to regulate patients' bowel movements; it is also important to take precautions against possible issues such as constipation and diarrhea during the recovery period.
• It is advisable to follow the diet and treatment plan determined by specialists.
• In suitable cases, extensive surgery is no longer needed; incision-free methods such as laser are a comfortable option for simple and moderate fistulas, while complex or recurrent cases may still require conventional surgery.
• Laser fistula treatment offers patients a comfortable alternative to sutures and other surgical methods, and successful outcomes can be achieved in suitable patients.
• Pain and discomfort during and after the procedure are minimal; because no sutures are placed, healthy tissue is left unharmed.
• Under local anesthesia, the treatment takes just 10 minutes.
• In abscessed or complicated fistulas, the fistula opening can be drained with a partial fistulotomy when needed. Thanks to non-surgical fistula treatment, patients can be seen and treated on the same day and quickly return to their social lives!
• Non-surgical laser treatment, which has become widespread in the treatment of anal fistulas in recent years, minimizes the risk of gas and stool incontinence.