Submucous Ligation Of Fistula Tract (SLOFT)
A new procedure for Fistula in Ano
(Minimally invasive and day care surgery)
This article is aimed for the consideration of this new procedure by the day care surgeons already practicing and proficient in fistula surgery, hence the unnecessary basics of anatomy, classification and detail of the methods of treatment of fistula in Ano is omitted.
Fistula in Ano is a complication of crypto glandular abscess.
The treatment is aimed at obliterating the internal opening and destruction of the distal tract without making the patient incontinent.
Various methods to treat and their analysis are as follows –
- Lay open the tract.
- Seaton in case of fistula above the puborectalis.
- Coring or division of sphincter and primary repair after excision of the tract
- Fistula plug.
This study started in January 17th 2014. It was an accidental innovation while trying to do LIFT. As it became difficult to find the tract in Inter Sphincteric plane , we proceded medially and found that it is easiest to find the tract where it emerged out, i.e just out side the internal opening. Hence it is named as SLOFT (Sub Mucous Ligation Of Fistula Tract).This is a pilot study. About 22 patients have been operated till early April 2014, with close follow up and documentation. No recurrence as yet. 5 surgeons have already started hence it is reproducible.
It was awarded as best paper in day care surgery conference Chennai in April 2014 and is being approved by many national and international stalwarts.
The external opening is canulated and normal saline with hydrogen peroxide is injected to define the internal opening. If it is unclear, Methylene blue is tried.
|It was observed that the primary closure was not successful.|
The problems of treating Fistula in Ano
- It is a morbid disease having 15 to 40% recurrence whatever the procedure.
- There is always fear of incontinence of which most of the patients are aware and concerned of.
- Patients are away from their job for a long time.
- The option to get early to job (VAAFT) is very costly incurring about 6- 7 lakhs of initial instrument cost and 5-7 thousand recurring cost for every procedure. Available in only higher centres with a package of around 70,000 to 100,000 rupees.
- The economically viable option is LIFT, but it requires an intense training, is difficult in even expert hands, hence cannot be reproduced easily, making it not popular though it being a wonderful technique.
- Other conventional methods like Laying open, seton carry a long painful recovery with daily dressings.
- Coring, excision and primary repair of sphincter is not every ones cup of tea, it requires high expertise and confidence with a great risk of incontinence.
Submucous Ligation Of Fistula Tract (SLOFT)
Is easy to operate and learn.
It does not require any dressings of multiple follow ups.
Patient can go back to work earlier than LIFT, though not immediately like VAAFT.
The operating time is only around 30 minutes, patient can go home the same day and get back to his job within 2-3 days.
The early results are encouraging. There is no early recurrence. Future will show the delayed results. All the patients are under close follow up with serial evaluation of wound and photographs.
Fecal incontinence and Recurrence
Patient and the operating surgeon as well, both are concerned of Fecal incontinence in early post op recovery and recurrence in delayed phase.
In SLOFT there is no recurrence because even the internal sphincter is not damaged ensuring the flatus continence also.
As the recurrence is concerned, patient has following inhibition to undergo the repeat procedure
- The fear of repetition of painful dressings and loss of job after conventional surgery.
- He cannot bear the cost of VAFT again.
- Very few are doing LIFT.
All the above concerns are ruled out in SLOFT. He will be ready for re operation and should be cured in one or two recurrences, just because it was less painful, economically viable and he went early to job after his first operation too!
Conclusion According to the early results of the procedure the morbidity seems very low, because the patients had to be called for follow up, as they had no significant post op problems. We requested them to come weekly to see the progress of wound. Except for cleanliness and sitz bath, no anti biotic local ointment was suggested. Oral antibiotics were given only for 5 days. Multicentral trial and long term follow up will truly analyze this new procedure.
Dr D.U.PathakMS FACRSI
Jabalpur (M.P) India
Mobile – 094251-52747