Category: Fistula

Author: Healing hands clinic

Pune colo-rectal surgeon Dr Ashwin Porwal has developed the minimally invasive DLPL technique to treat complex fistulas

For 12 long years, US-based Julie Rogers suffered from a Grade 5 super complex fistula. Her personal health challenges made her seek a series of treatments that unfortunately did not offer long-term relief. She had no idea what to expect though when she arrived in Pune in July where Dr Ashwin Porwal and his team’s “healing hands” performed the Distal Laser Proximal Ligation (DSPL) procedure and freed her from pain.

There are various kinds of fistula and Dr Porwal’s patients vouch for a cent per cent cure. Take for instance Pune’s Dr Saloni Joshi who developed an obstetric fistula – a hole between the birth canal and bladder and/or rectum caused by prolonged obstructed labour – but was cured completely.

WHAT IS A COMPLEX FISTULA?

An anal fistula is a small tunnel that develops between the end of the bowel and the skin near the anus. “Fistula-in-ano is one of the most commonly encountered surgical problems with the prevalence of average 2/10,000,” says Dr Porwal, founder of Healing Hands Clinic in Pune and a noted colorectal surgeon who specifically designed the Distal Laser Proximal ligation procedure for highly complex anal fistulas.

The condition has been known since ages and different management techniques for it have been suggested in medical literature. But it continues to be one of the most challenging clinical problems in anorectal surgery.

Various surgical interventions have had variable success. The surgical management of complex fistula is usually aimed at the permanent elimination of the suppurative process by drainage of sepsis and removal of fistula tracts while maintaining sphincter integrity.

Recently, the Indian Journal of Colo-Rectal surgery has concluded that minimally invasive, sphincter-saving DLPL surgery is safe and effective treatment for complex fistula‐in‐ano. “This is a minimally invasive sphincter saving surgery for complex fistulas. Basically it addresses the intersphincteric space which is the root cause of complex fistula,” says Dr Porwal, who has performed 4,661 such surgeries till date. In Julie’s case, an inflammatory bowel disease (Crohn’s disease) led to the fistula developing between one loop of intestine and another.

WHAT IS THE DLPL SURGERY?

Dr Porwal explains that the DLPL is based on two principles. One is debridement, which is a procedure for treating the wound on the skin. Inefficient debridement is one of the causes of recurrence in fistula. This is achieved in a minimally invasive way by using a laser, which takes care of the fibrosis associated with complex fistulas. The debridement is thorough and deep with the use of a laser, which can be easily negotiated within the Intersphincteric space and supralevator space.

“The other principle is the efficient drainage from the fistula in the first two to three weeks which is the key to success in curing it after surgery,” he says.

DLPL is performed under the guidance of a 3D EndoAnal Imagine machine which can identify hidden fistula tracts and micro abscess in real time during surgery. That is the key in getting assured results with surgery. It also minimises the risk of damage to sphincter muscles.

Widening of the external opening serves that purpose while superficial incision over the internal opening helps in proper drainage in the initial three weeks after surgery. This is achieved by timely follow-up planned at five days, two weeks, four weeks and six weeks. “That is the reason why DLPL is associated with a negligible recurrence rate,” Dr Porwal says.

There is no need for daily dressing with DLPL and the patient can resume work in about five days. There is also no risk of incontinence as sphincter muscles are not incised, says Dr Porwal, who has trained over 250 surgeons in the country and worldwide.

 

Long-term follow-up of 683 operated patients shows a 99% success rate

Whether he would lose bowel control was one thing that weighed heavily on Ankit’s mind prior to undergoing surgery for anal fistula. “It has been more than two years now. I am completely fine post-surgery,” said Ankit, a software professional.

Ankit was part of an observational study comprising long-term follow-up of 683 operated patients with complex anal fistula for 30 months.

The study has shown that a minimally-invasive laser surgery technique can cure patients with complex anal fistula without causing bowel/anal incontinence – a known postoperative complication. The surgical technique also significantly reduces the recurrence rate which is very high in patients with anal fistula.

“Anal fistula is often considered a dilemma because of postoperative incontinence and recurrence rate. Using a distal laser proximal ligation technique (DLPL) – a minimally invasive sphincter-saving surgery, we could address anal incontinence and recurrence in 99% of our operated patients,” said Pune-based colorectal surgeon Dr. Ashwin Porwal.

Dr. Porwal’s study got published in a reputed index journal – Indian Journal Of Colorectal Surgery – recently.

Patients with anal fistula harbor apprehension of developing anal or bowel incontinence post-surgery. The bowel incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control. It can significantly impact the quality of life.

“The goal of the surgery is a balance between getting rid of the fistula while protecting the anal sphincter muscles, which could cause incontinence if damaged. The DLPL technique deals with the root cause of complex fistula that is the internal opening and inter-sphincteric abscess,” Dr Porwal said.

DLPL is specifically designed for highly complex anal fistulas. “That’s why it has a 99 % success rate even in patients with type 4 complex anal fistula,” Dr. Porwal said.

Core principles of the DLPL technique are accurate diagnosis based on a 3D endoanal imaging probe, adequate debridement of the fistula tract with a radial Laser fiber, efficient drainage of the abscess in the first three weeks post-surgery, and excellent post-operative wound care.

“Follow-up after surgery is the key to success. A minimum of three follow-ups are required. First at 2nd week, then 5th week and finally at 8 weeks,” he said.

When probed why the study did not compare DLPL results with other laser treatments meant for anal fistulas, Dr. Porwal said, ” Ours is the only published study till date on highly complex anal fistulas with use of laser. Most of the studies – available for laser treatment in fistula – are for moderate cases but not specific to type 4 or highly complex cases.”

Every study has certain limitations. “In our case, it was a single-center study. But very soon we are planning to do a multiple center study. Adequate training of the surgeons is a must before that,” Dr. Porwal said, adding, “To date, we have operated on more than 5,500 cases of complex fistula. Very soon we will be publishing the results of our long-term follow-up study of operated patients for five years.”

Dr. Jaya Maheshwari, a senior member of the Indian Association of Gastrointestinal Endosurgeons (IAGES) Jaipur was the first surgeon outside Pune to get trained under Dr. Porwal in 2014. “I have performed DLPL technique on more than 200 patients with highly complex anal fistula by now with a similar success rate of 98-99 %,” Dr. Maheshwari said.

BOX

Why the study?

The surgical management of complex fistula carries a greater risk of incontinence, due to the involvement of the anal sphincter muscles

There are many surgeries performed for complex anal fistulas, but their success rates are variable

There is no single technique that can be called a gold standard in managing complex cases

The surgery with good-postoperative healing, with minimal or no functional loss, and less recurrence is need of the hour

This study was conducted to evaluate the efficacy of a novel technique, DLPL surgery, in the treatment of complex anal fistula

This study aimed to objectively assess the impact of operative treatment using the DLPL technique on quality of life-related to anal incontinence, recurrence

The study design

The study Included 683 operated patients of highly complex anal fistula with the DLPL technique between January 2013 and December 2017 with a minimum long term follow up of over 30 months

Most of the patients were working in the IT industry

Most of the patients were discharged the next day of surgery

The average time required to resume normal activities was less than a week

The overall success rate of the DLPL technique was 98.98% with a minimum long-term follow-up period of 30 months

Complete healing time was average 10 weeks for most of the cases

The study has concluded that the DLPL technique is minimally invasive,sphincter-saving, and has a negligible recurrence rate

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With the medical field flourishing at a steady rate, healthcare has been witnessing a radical change in the way we approach treatment of various diseases. A lot of these advancements are further supplemented by unparalleled medical expertise and that is exactly whatsuper-speciality Proctology centre Healing Hands Clinic offers to all its patients. Proctology is a branch of medicine that deals with anorectal conditions like Piles, Fistula, Constipation, Fissure, Pilonidal Sinusamongst others. Healing Hands is India’s first chain of Proctology clinics offering cutting edge treatment options to patients suffering from these ailments. Each clinic is a state-of-the-art centre headed by an expert Laser surgeon with considerable experience in treatment of aforementioned conditions.

Of all anorectal disorders, an Anal Fistula is undoubtedly the most challenging to treat as recurrences are quite common. In this condition, an abnormal communication develops between the rectum/anal canal and the outer skin. This is where the expertise and experience of surgeons at Healing Hands comes in handy. Founded by renowned surgeon Dr Ashwin Porwal, all the procedures done at Healing Hands are Laser based, well-researched and backed by sound medical knowledge. For Simple Fistula, a technique called FiLaC – Fistula Laser Closure is used. For Complex and Recurrent Fistula, an innovative, sphincter-saving technique called DLPL – Distal Laser Proximal Ligation is used.These Laser based techniques ensure complete recovery and have a negligible chance of recurrence. Besides, they have a reputation of faster healing, minimal complications and a quicker return to normalcy for the patient. Statistics so far state thaton an averagethere is about 30% chance of recurrence in treated cases of Fistula. However, at Healing Hands, the numbers are at a mere 2% which clearly exhibits a sturdy success rate of the surgicalexpertiseoffered at this holistic clinic.In fact, Healing Hands is well known worldwide for treatment of highly complex and recurrent cases.All operated patients are thoroughly followed up until complete cure.

DLPL technique that was developed by Dr Porwal is an innovative procedure for complex and recurrent cases. The sphincter muscles remain safe and the patient does not run a risk of post-operative loss of control over motions (incontinence). Healing Hands Clinic has published a research paper on a series of 100 patients with Complex High Fistulas treated with DLPL in which there was not a single case of recurrence or Incontinence.

Fistula-in-ano, a silent yet agonizing ailment, has always posed a treatment challenge to surgeons worldwide. The refractory nature of Fistula along with its tendency to recur continues to leave the best doctors perplexed. Consequently, those suffering from this condition find themselves anxiously searching for a definitive cure. In light of this scenario, Dr. Ashwin Porwal, renowned Proctologist and founder of Healing Hands Clinic, India, set out on devising a technique called DLPL that provides an assured and lasting cure.

Anal Fistula aka Fistula-in-ano is an abnormal track that forms between the anal canal and the skin around the anus. It is commonly associated with a collection of pus in the bottom area called Rectal Abscess. Symptoms may be due to the underlying Abscess or due to Fistula per se. This includes throbbing pain, oozing of pus/watery fluid, swelling, itching and foul odor. Diagnosis is confirmed by a simple test called Proctoscopy. For a detailed study of the abscesses and track branching, Dr. Porwal introduced 3D Endo-anal Imaging. This imaging can also be used intra-operatively thus increasing the precision of the surgery.

Until recent times, Fistula was treated using different techniques like Fistulectomy, VAAFT, LIFT, Ksharsutra, Fistula Plug etc. However, these conventional techniques were quite painful or had high recurrence rates. Being a Proctologist, Dr. Porwal would come across a large number of previously treated Fistula cases who were rendered helpless after recurrences. Subsequently, he developed his own technique DLPL (Distal Laser Proximal Ligation). In this procedure, any abscess cavity along with the internal opening is first excised. This is followed by the closure of the distal tract. The proximal part of the fistula track is then sealed with the Laser energy. With the radially emitting fiber of the laser, energy is applied circumferentially to the track ensuring it’s complete ablation. Complete healing takes about 8 weeks on average.

Using this technique Dr. Porwal has treated Complex and Recurrent Fistulae with noteworthy success. Patients from across the globe come to Healing Hands Clinic in the hope of a cure. Dr. Porwal has presented numerous research papers at national and international conferences. The benefits of DLPL will definitely bring hope to despondent patients of Fistula who muddle along for years in search of a cure.

With technological advances in medical field, we are witnessing great developments in treatment of various diseases. These advancements are further validated by impeccable medical expertise and that is exactly what super-speciality Proctology centre Healing Hands Clinic offers to all its patients. Proctology is a branch of medicine that deals with anorectal conditions like Piles, Fistula, Constipation, Fissure, Pilonidal Sinus and Prolapse amongst others.
What Is an Anal Fistula?
In its simplest form, it is a tunnel with one opening inside the lining of your anus and another opening in the skin of your butt. The noticeable symptoms include opening in the skin of the buttock with discharge of blood or foul-smelling pus, redness and swelling, and pain.
Laser: An assured treatment modality for Fistula
Fistula is a complex disease. It hardly ever recovers on its own, and once formed, needs some degree of surgical intervention. Ultimately, the aim of any fistula treatment is, firstly, to get rid of the tract while saving the sphincter muscle. Secondly, the treatment should be such that chances of recurrence are minimal. The latest improvisations on the conventional ways to treat fistula include procedures like FiLaC (Fistula Laser Closure) and DLPL (Distal Laser Proximal Ligation). The principle behind these techniques is to use defined energy to circumferentially vaporize and close the fistula tract while sparing the muscle around it. Laser is quick, precise, and the post-procedure healing is excellent. DLPL provides promising results in complicated and recurrent cases.
Fistula is notorious for its recurrence or its tendency to come back after treatment. However, a large number of Recurrent Fistulas have been successfully cured at Healing Hands. The statistics so far state that on an average there are about 30% chances of recurrence in treated cases of Fistula. At Healing Hands, the numbers are at a mere 2% which clearly exhibits a sturdy success rate of the surgical expertise offered here. Research papers on DLPL have been presented at various national and international conferences and the procedure has received a thumbs-up from the surgical community.

For appointments:
Healing Hands Clinic
Pune Station / Tilak Rd: 88882 88884
Kondhwa: 88885 22226
Baner: 88886 22221
Chinchwad: 88882 00004
Chakan: 88882 96666
Website: www.healinghandsclinic.co.in
Email: info@healinghandsclinic.co.in

An error in clinical judgement literally turned a young doctor’s life into a nightmare for three long years, during which he consulted six specialists who treated him for everything, but

complex anal fistula

— the condition he was suffering from.

It was only after Aamir

(33), a Bangladeshi practising as a doctor in Australia, consulted a doctor in Pune that he was diagnosed correctly. He was operated upon here on January 17.

Aamir used to have intermittent pain in his bottom after passing off the stool. “The pain would go away within two to three days to resurface again,” he said, adding that the first episode of tremendous pain and large abscess formation occurred in July 2015.

In 2016, he was almost bedridden due to the condition. He lost 22kg weight in four months as he could eat only two bread slices to avoid defecation.

Aamir attributed the cause of his condition to lactose intolerance. “My liking for milk aggravated my problem to the extent that I ended up injuring my bowel,” he said.

Aamir initially consulted doctors at a hospital in Australia, but his condition did not improve. He then consulted another specialist who “misdiagnosed his symptoms as that of anal fissure”.

In February 2016, Aamir had his colonoscopy done at another hospital in Australia where doctors found a lesion in the lower bowel on the left side. “But they completely misdiagnosed it as a mucosal prolapse,” he said.

As the pain persisted, the doctors did a CT scan on Aamir’s earnest request and admitted him to a hospital on September 2, 2016. “This was the time that I had my first abscess drain surgery. But sadly, the doctors did not find any opening in my rectal wall. Eventually, I had seven abscess drain surgeries done and every time the treating doctors failed to find an internal opening or fistula,” Aamir alleged. Frustrated and sullen, Aamir came across the work of Pune-based proctosurgeon Ashwin Porwal while browsing on internet for a probable cure to his condition. He eventually flew down to Pune in January 2018.

When contacted, Porwal said, “Recurrent abscess have tendency to form fistula. To obtain accurate diagnosis, we do 3D endo anal pelvic floor imaging. This facility is available at select places across the world,” said Porwal.

Aamir is doing well postsurgery.

Anal fistula or fistula-in- ano is an abnormal hollow tract or cavity between primary opening inside the anal canal to a secondary opening in the perianal skin; secondary tracts may be multiple and can extend from the same primary opening. Different types of anal fistulas are classified by their location. In order of most common to least common, the various types include:

Inter-sphincteric fistula : The tract begins in the space between the internal and external sphincter muscles and opens very close to the anal opening. It is a tract between two anal sphincters.

Transphincteric fistula : The tract begins in the space between the internal and external sphincter muscles or in the space behind the anus. It then crosses the external sphincter and opens an inch or two outside the anal opening. These can wrap around the body in a U shape, with external openings on both sides of the anus. It is also called as horseshoe fistula.

Suprasphincteric fistula : The tract begins in the space between the internal and external sphincter muscles and turns upward to a point above the puborectal muscle, crosses this muscle, then extends downward between the puborectal and levator ani muscle and opens an inch or two outside the anus

Extrasphincteric fistula : The tract begins at the rectum and extends downward, passes through the levator ani muscle and opens around the anus. These fistulas are usually caused by an appendiceal abscess, diverticular abscess or Crohn’s disease.

Cause of Fistula in ano – The most common cause of fistula is an anal abscess, though there are several other possible causes which may lead to fistula in ano which can be stated as follows:

1.Anal Abscess : An abscess is a collection of pus in an area of the body. An anal abscess develops when a small anal gland becomes infected with bacteria. It can be very painful and is one of the utmost reason which causes fistula. Approx 80% of cases having fistula are caused by abscess

2.Intestinal Inflammation : Intestinal inflammation which causes due Crohn’s disease which is a type of inflammatory bowel disease and Diverticulitis which is a condition which leads to inflammation of the small out pouching or diverticulitis which forms a number of tiny pockets from the side of the colon.

3.Malignancy in the an rectal area can lead to fistula in anal area.

4.Infections – Infection like Human Immunodeficiency Virus(HIV), Acquired Immunodeficiency Syndrome(AIDS),Tuberculosis etc are infections which leads to fistula

4.Iatrogenic – As a complication of a previous surgery in the region.
Symptoms of Fistula in Ano

Possible symptoms include:

1. Constant pain and discomfort which is throbbing and worsens when sitting down.

2. Skin irritation around the anus which includes swelling and tenderness.

3. Pus discharge

4. Constipation

5. Fever

 

Diagnosis of Fistula in Ano:

1. A brief history and required information is taken which is then followed by a clinical examination along with a digital rectal examination which is enough to diagnose an anal fistula

2. Proctoscopy – A small inspection of the rectum is done with a small tube like scope called as proctocopy to check for any concomitant condition in rectum area.

In certain conditions doctors may also take help of MRI Fistulogram if the fistula tract is difficult to diagnose.

Treatment for Fistula in ano (Anal Fistula)

There are two approaches to treatment of Anal Fistula viz. Traditional technique and Modern technique.

A)Traditional Technique include :

1. Fistulectomy : This process involves cutting open the whole length of the fistula in so that the surgeon can flush out all the content in the fistula. The fistula tract is removed and the groove which is formed is left behind to heal. This procedure comes with a risk of damaging the sphincter muscle which results in fecal incontinence and is usually used for treatment of complex anal fistula.

2. Ksharsutra : This technique has an Ayurvedic approach in which a thread of a special kind which is coated with ayurvedic medications is inserted into a fistula tract. This kind of treatment has no cuts and stitches but also needs to be done in multiple weekly sessions that is completed over a few months

B) Modern Technique include :

1. Video Assisted Anal Fistula Treatment : Also known as VAAFT is a technique used for a surgical treatment of complex fistula and is preformed with the help of a fistuloscope

2. Ligation of Intersphincteric Fistula tract : Also known as LIFT is a technique used to treat a complex or deep anal fistula. A seton is firstly placed in the tract which forces it to widen over a period of time. A few weeks later, the surgeon doctor removes the infected tissue and closes the internal fistula opening.

3. Fistula plug : A fistula plug is a plug that is 100% synthetic bio-absorbable scaffold. The fistula plug is placed in the fistula tract. Over a period of time the cells from the body migrate into the scaffold and new tissues are generated as the body absorbs the plug material which leaves no permanent material in the body.

4. Fistula-tract laser closure – Also known as Filac is done using Leonardo laser which was first introduced in India by Dr Ashwin Porwal at Healing Hands Clinic. This procedure helps in gently removing the fistula tract without damaging the sphincter muscle.

5. Distal Ligation Proximal laser – Known as DLPL aims not only at treating fistula but also to save the sphincter muscle which helps to prevent incontinence and to prevent recurrence, considering the nature of the fistula.In this treatment of fistula, firstly abscess cavity with internal opening is excised and then closing of distal tract is done. The proximal area of fistula tract is then sealed with the help of Leonardo laser which helps in complete closure of tract.

For more information on anal fistula you can click on the following link :https://www.healinghandsclinic.co.in/fistula-treatment-centre/

For appointments : https://www.healinghandsclinic.co.in/online-appointment/