Comparative Evaluation of IFTAK and LAFT Techniques in the Management of Trans-Sphincteric Fistula-in-Ano: A Prospective Study

Abstract

Introduction

Anorectal fistulas are chronic abnormal connections between the anal canal and perianal skin, often resulting from cryptoglandular infections. Despite advancements in surgical techniques, recurrence remains a significant challenge. Traditional methods like fistulotomy and seton placement show variable success rates, while newer sphincter-sparing approaches like IFTAK and LAFT offer promise. This study compares the efficacy of IFTAK and LAFT in managing trans-sphincteric fistulas.

Methods

This prospective study at Sir Sundar Lal Hospital, BHU, compared IFTAK and LAFT for managing trans-sphincteric fistula-in-ano. Forty-four patients were randomized into two groups (22 each). Patients underwent preoperative preparation, postoperative care, and follow-ups at regular intervals. Outcomes, including pain (VAS), healing, and recurrence, were analyzed statistically using SPSS.

Results

Group A (IFTAK) showed significantly lower recurrence rates (0% vs. 27.3%, p = 0.000) and superior healing of the fistulous tract compared to Group B (LAFT). Pain reduction, discharge, inflammation, and induration improved significantly in both groups (p < 0.001). However, Group A demonstrated faster pain reduction and better wound dryness at 45 and 60 days (p < 0.05). Hospital stays were shorter in Group A. Overall, IFTAK exhibited better clinical outcomes and fewer complications.

Conclusion

The study indicates that IFTAK is more effective than LAFT for managing trans-sphincteric fistulas, with no recurrences, better healing, and higher success rates, especially for posterior fistulas. LAFT offers less pain, and shorter hospital stays but has a higher recurrence rate. Combining IFTAK and LAFT may optimize outcomes, warranting further research.

Keywords

trans-sphincteric fistula management - IFTAK - LAFT - sphincter preservation - recurrence rate

Introduction

Anorectal fistula is a relatively common, chronic connection between the anal canal and perianal skin.[1]

The Parks hypothesis, which proposes that perianal fistulas arise from inflammation of the anal glands, is a commonly held view about cryptoglandular fistulas.[2] This blockage can lead to the formation of an abscess, and the path taken by the abscess may become chronically inflamed and lined with epithelial tissue. If an abscess is not properly drained, it can result in a systemic infection. Patients may report symptoms such as anal pain, or itching. In more severe or chronic cases, they may also experience skin breakdown, swelling, fever, or foul-smelling pus discharge.[3] Less common causes of anorectal fistulae include conditions such as Crohn's disease, trauma, radiation, foreign objects, infections, and malignancies.[4] To accurately assess the anatomy of the fistula, the surgeon should conduct a comprehensive evaluation. This involves a combination of visual inspection, digital rectal examination, and anoscopy, potentially using aids like hydrogen peroxide or fistula probes to locate both the internal and external openings. For recurrent or occult fistulas, or when there is a strong suspicion of complexity (particularly due to Crohn's disease), magnetic resonance imaging (MRI) or endoanal ultrasound (EAUS) can be used as additional tools to define the anatomy better. MRI has been shown to match operative and clinical findings in 82% of anorectal fistula cases.[5]

While surgery is the primary treatment for anorectal fistulas, understanding the anatomy is crucial.[6] Common classification systems, based on the relationship to internal and external sphincter muscles, include Park's (1976), St. James University (2000), and Garg (2017). The latter two incorporate MRI to assess fistula complexity and guide treatment.[7] [8] [9]

Which, most widely adopted and practical classification for anal fistulas is the one proposed by Dr. Parks, centered on the location of intersphincteric anal gland infection. In 1976, Dr. Parks published a paper outlining this system, which continues to be commonly used today.[7]

Managing fistula-in-ano has always been challenging, especially in eliminating the fistula while preserving sphincter function. Both sphincter-sparing and sphincter-cutting procedures have been used, with newer techniques like fibrin glue and anal fistula plugs gaining attention. Despite advancements, achieving successful management with minimal recurrence and complications remains a complex task for surgeons. Treating fistula-in-ano remains a major challenge due to issues like recurrence.[10]

Various surgical procedures are available for the treatment of anal fistulas, each with different recurrence rates. Fistulotomy[11] has a recurrence rate of 12%, while fistulectomy[12] shows a higher rate between 30-50%. The seton[13] procedure has a low recurrence rate of 5.88%. Fibrin glue[13] has a recurrence rate of 20%, and the anal fistula plug[14] is associated with a 17% rate. Endorectal advancement flap[15] and video-assisted anal fistula treatment (VAAFT)[16] both show a 12% and 18% recurrence rate, respectively.

Similarly, the ligation of the intersphincteric fistula tract (LIFT)[17] has an 18% recurrence rate. The use of a chemical seton, such as Guggulu Ksharsutra,[18] has a significantly low recurrence rate of 3.3%. The IFTAK[19] procedure has a recurrence rate of 3-7% over a two-year follow-up, while LAFT[20] has the highest rate of 40%.

Despite advancements, achieving successful management with minimal recurrence and complications remains a complex task for surgeons. Treating fistula-in-ano remains a major challenge due to issues like recurrence. Despite numerous techniques proposed over time, none have fully solved these problems. However, innovative approaches like IFTAK and LAFT show promise in addressing persistent challenges in fistula management. The IFTAK technique has been used for treating complex and recurrent fistula-in-ano. While successful, no comparative studies with LAFT or FiLac have been conducted. This study compares IFTAK with LAFT in managing trans sphincteric fistula-in-ano.

Patients and Methods

This prospective study was conducted in the Department of Shalya Tantra, Faculty of Ayurveda, Sir Sundar Lal Hospital, BHU, Varanasi, to evaluate the effectiveness of two treatments—Interception of Fistula Tract and Application of Ksharsutra (IFTAK) and Laser Ablation of Fistula Tract (LAFT)—for managing trans-sphincteric fistula-in-ano (Bhagandara). After obtaining informed consent from patients or their representatives, a comprehensive physical examination was conducted. Patients aged 18–60 years, of all genders, were recruited from the National Resource Center on Ksharsutra Therapy OPD, based on the criteria for uncomplicated trans-sphincteric fistula as per Parks' classification (1976).

Out of 52 selected patients, 44 were ultimately included in the study after some patients opted out. These were divided into two groups: Group A (22 patients) received IFTAK, and Group B (22 patients) received LAFT. Patients were advised to maintain hygiene, take mild laxatives, and use prescribed medicines to control local infection and inflammation. Preoperative preparations included tetanus toxoid administration, xylocaine sensitivity testing, and routine tests. Upon discharge, patients received prescriptions for pain relief, and oral drugs were instructed to minimize physical activity and avoid straining for 4–8 weeks. All patients were given guidance on wound care, including thorough cleaning and applying medicated ointment after bowel movements and at bedtime. Patients were instructed to visit the NRC OPD weekly, with follow-ups scheduled at 15, 30, 45, 60, 90, and 120 days post-procedure. Patients were advised to return to the clinic immediately if any symptoms arose. During each visit, a Visual Analogue Scale (VAS) for pain was assessed. Recurrence was monitored through clinical exams and MRI. Patients were considered cured if both the external and internal openings had closed with no discharge, pain, or swelling. Recurrence was assessed 120 days post-procedure. Statistical analyses were performed using SPSS (Version 26.0). Results were presented as means and standard deviations, frequencies, or proportions. To compare results between groups, Mann Whitney test was used, and Chi-square test was applied and the Friedman test was used to compare within the group.

Surgical Technique

IFTAK (group A) ([Fig. 1])

Fig. 1 IFTAK -GROUP A.

The procedure began with the patient in the lithotomy position, with perianal region preparation done through painting and draping. Under local anesthesia, the infected anal crypt and internal opening were identified using a digital rectal exam, and the fistulous tract and any branching were examined with a malleable probe. A 2-2.5 cm vertical incision was made in the anterior or posterior midline, followed by dissection to expose and intercept the fistulous tract, which appeared as a whitish structure. If an abscess cavity was present, it was dissected in the intersphincteric space, and probing was performed through the intercepted tract to the internal opening. A plain surgical linen thread (No. 20) was then applied.

Postoperative pain was managed with oral NSAIDs, and patients were monitored for two hours for complications like bleeding. Patients were advised to take sitz baths twice daily to keep the wound clean. They revisited the hospital on the 7th day for ksharasutra replacement, assessment of wound healing, and external opening condition. In each follow-up, the ksharasutra was replaced using the railroad technique, ensuring drainage until the external opening healed, and the thread was then snugly tied to gradually open and heal the fistulous tract.

LAFT (group B) ([Fig. 2])

Fig. 2 LAFT -GROUP B.

The procedure began with the patient in the lithotomy position, with preparation of the perianal region by painting and draping. Under local anesthesia, the infected anal crypt and internal opening were identified through digital rectal examination, and the fistulous tract and branches were assessed with a malleable probe. The tract was then cleaned with a curette and rinsed with saline. IMDSL Medical Diode Laser was used for LAFT surgical procedure ([Figs. 3] and [4])

Fig. 3 IMDSL Medical Diode Laser device.

Fig. 4 IMDSL Medical Diode Laser used for LAFT Surgical Procedure.

A laser probe was inserted into the external opening and extended through the tract to the internal opening. The probe tip was retracted slightly before applying the laser at 200 J, advancing it as needed to clear any untreated areas. After every three laser applications, the probe tip was cleaned with hydrogen peroxide to prevent carbon buildup. The fiber was retracted at 1 mm/sec for consistent energy release, as recommended by Giamundo. Laser use was stopped when the probe was close to the external opening. Finally, an ice pack was applied for 1–2 minutes, with no ointments or topical medications applied post-procedure.

The adjuvant therapy included mild analgesics for pain and short courses of antibiotics in cases of severe inflammation or pus. Patients were advised to take hot sitz baths after defecation to maintain wound cleanliness and reduce discomfort. A healing agent was applied daily to aid recovery, and Kanchanar Guggulu was given twice daily for inflammation. Constipated patients were given a laxative (Isabgol) at bedtime to promote regular bowel movements. Patients were encouraged to resume daily activities, follow a high-fiber diet rich in vegetables and fruits, and avoid coffee, alcohol, spicy foods, prolonged sitting, and strenuous activities.

Observation and Result- ([Table 1])

Table 1 Observation and Result

Demographic parameters and other characteristics	Group A (n = 22)	Group B (n = 22)	Total (n = 44)
Internal Opening Location
Anterior	5 (22.7%)	14 (63.6%)	19 (43.2%)
Posterior	17 (77.3%)	8 (36.4%)	25 (56.8%)
Primary Crypt Location and Grade
Anterior (Grade 1)	2 (40%)	7 (50%)	19 (43.2%)
Anterior (Grade 2)	2 (40%)	7 (50%)
Anterior (Grade 3)	1 (20%)	0 (0%)
Posterior (Grade 1)	7 (41.17%)	4 (50%)	25 (56.8%)
Posterior (Grade 2)	5 (29.41%)	2 (25%)
Posterior (Grade 3)	5 (29.41%)	2 (25%)
Previous Treatment History
Conservative	14 (63.6%)	14 (63.6%)	28(63.6%)
One Surgery	5 (22.7%)	3 (13.6%)	8 (18.2%)
Two or More Surgeries	0 (0%)	3 (13.6%)	3(6.8%)
No Prior Treatment	3 (13.6%)	2 (9.1%)	5(11.4%)
Chronicity of Disease
Less than 6 months	13 (59.1%)	15 (68.2%)	26 (63.6%)
Less than 12 months	7 (31.8%)	3 (13.6%)	10 (22.7%)
Less than 18 months	1 (4.5%)	2 (9.1%)	3 (6.8%)
Less than 24 months	1 (4.5%)	2 (9.1%)	3 (6.8%)
Age Distribution
≤20 years	1 (4.5%)	1 (4.5%)	2(4.5%)
21-30 years	7 (31.8%)	10 (45.5%)	17 (38.6%)
31-40 years	4 (18.2%)	9 (40.9%)	13 (29.5%)
41-50 years	6 (27.3%)	1 (4.5%)	7 (15.9%)
51-60 years	4 (18.2%)	1 (4.5%)	5 (11.4%)
Gender Distribution
Male	22 (100%)	20 (90.9%)	42 (95.5%)
Female	0 (0%)	2 (9.1%)	2 (4.5%)

(primary crypt location in the anal canal: Grade 1 with the internal opening at the anal verge, Grade 2 at the pectinate line, and Grade 3 at the anorectal ring.)

In this study, the highest prevalence of trans-sphincteric fistula-in-ano was observed in patients in their 30s and 40s, with males being significantly more affected than females. Most internal openings were in the posterior half of the anal canal, and the majority of patients had previously undergone conservative treatment. A substantial number of cases presented with a chronic disease duration of 6 to 24 months. During treatment, patients undergoing IFTAK (Ksharsutra therapy) experienced significantly more pain, discharge, and mild increases in induration and inflammation compared to those treated with LAFT. However, the LAFT group had a delayed drying of the external opening, a higher recurrence rate of 27.3%, and required shorter hospital stays. Complete healing was more frequent with IFTAK, which also showed no recurrences, indicating an overall superior efficacy compared to LAFT.

Result ([Table 2])

Table 2 Result

PARAMETER	DAYS	GROUP A	GROUP B	STATISTICAL ANALYSIS
1. Effect of Pain	15	100% grade 3 pain	77.3% grade 3, 22.7% grade 2 pain	p = 0.019 (Mann-Whitney)
	30	81.8% grade 3 pain	36.4% grade 3, 59.1% grade 2 pain	p = 0.002 (Mann-Whitney)
	45	77.3% grade 2 pain	72.7% grade 2, 27.3% grade 1 pain	p = 0.350 (Mann-Whitney)
	60	54.5% grade 2 pain	54.5% grade 2, 9.1% grade 0 pain	p = 0.030 (Mann-Whitney)
	90	22.7% grade 1 pain	4.5% grade 1 pain	p = 0.082 (Mann-Whitney)
	120	100% grade 0 pain	95.5% grade 0 pain, 4.5% grade 1 pain	p = 0.317 (Mann-Whitney)
		Within-group: Significant reduction in pain	Within-group: Significant reduction in pain	p < 0.001 (Friedman)
2. Srava (Wound Discharge)	15	100% grade 3 discharge	100% grade 3 discharge	p = 1.000 (Mann-Whitney)
	30	22.7% grade 2, 77.3% grade 3	59.1% grade 2, 40.9% grade 3	p = 0.015 (Mann-Whitney)
	45	77.3% grade 2, 9.1% grade 3	54.5% grade 2, 9.1% grade 3	p = 0.160 (Mann-Whitney)
	60	45.5% grade 2, 36.4% grade 1	54.5% grade 1, 22.7% grade 2	p = 0.160 (Mann-Whitney)
	90	100% grade 0 discharge	100% grade 0 discharge	p = 1.000 (Mann-Whitney)
	120	100% grade 0 discharge	72.7% grade 0, 22.7% grade 1 discharge	p = 0.009 (Mann-Whitney)
		Within-group: Significant decrease in discharge	Within-group: Significant decrease in discharge	p < 0.001 (Friedman)
3. Induration	15	100% grade 1 induration	100% grade 1 induration	p = 0.150 (Chi-square)
	30	86.4% grade 1, 13.6% grade 0	68.2% grade 1, 31.8% grade 0	p = 0.220 (Chi-square)
	45	50% grade 0, 50% grade 1	68.2% grade 0, 31.8% grade 1	p = 0.220 (Chi-square)
	60	100% grade 0 induration	90.9% grade 0, 9.1% grade 1	p = 0.148 (Chi-square)
	90	100% grade 0 induration	95.5% grade 0, 4.5% grade 1	p = 0.312 (Chi-square)
	120	100% grade 0 induration	95.5% grade 0, 4.5% grade 1	p = 0.312 (Chi-square)
		Within-group: Significant decrease in induration	Within-group: Significant decrease in induration	p < 0.001 (Friedman)
4. Inflammation	15	100% grade 1 inflammation	95.5% grade 1, 4.5% grade 0 inflammation	p = 0.312 (Chi-square)
	30	90.9% grade 1, 9.1% grade 0	86.4% grade 1, 13.6% grade 0	p = 0.635 (Chi-square)
	45	59.1% grade 0, 40.9% grade 1	72.7% grade 0, 27.3% grade 1	p = 0.340 (Chi-square)
	60	100% grade 0	86.4% grade 0, 13.6% grade 1	p = 0.073 (Chi-square)
	90	100% grade 0	95.5% grade 0, 4.5% grade 1	p = 0.312 (Chi-square)
	120	100% grade 0	95.5% grade 0, 4.5% grade 1	p = 0.312 (Chi-square)
		Within-group: Significant reduction in inflammation	Within-group: Significant reduction in inflammation	p < 0.001 (Friedman)
5. External Opening Dryness	15	100% grade 0 (dry)	100% grade 0 (dry)	No significant difference
	30	100% grade 0 (dry)	100% grade 0 (dry)	No significant difference
	45	72.7% grade 0, 27.3% grade 1	100% grade 0 (dry)	p = 0.008 (Chi-square)
	60	0% grade 0, 100% grade 1	63.6% grade 0, 36.4% grade 1	p = 0.000 (Chi-square)
	90	100% grade 1	100% grade 1	No significant difference
	120	100% grade 1	72.7% grade 0, 77.3% grade 1	p = 0.018 (Chi-square)
		Within-group: Significant change in dryness	Within-group: Significant change in dryness	p < 0.001 (Cochran)
6. Healing Status of Fistulous Tract	90	40.9% grade 0, 59.1% grade 1	100% grade 1	p = 0.001 (Chi-square)
	120	100% grade 1	27.3% grade 0, 72.7% grade 1	p = 0.008 (Chi-square)
		Within-group: Significant improvement	Within-group: Significant improvement	p = 0.004 (McNemar)
7. Recurrence	120	100% no recurrence	72.7% no recurrence, 27.3% recurrence	p = 0.000 (Chi-square)
8.Hospital stay	DAYS	TOTAL NO. & %	TOTAL NO. & %	TOTAL NO. & %
		GROUP A	GROUP B
	1	0/0%	9/40.9%	9/20.5%
	2	2/9.1%	3/13.6%	5/11.4%
	3	3/13.6%	10/45.5%	13/29.5%
	4	0/0%	0/0%	0/0%
	5	13/59.1%	0/0%	13/29.5%
	6	4/18.2%	0/0%	4/9.1%
	TOTAL	22/100%	22/100%	44/100%

Grading criteria include: Pain (0 = none, 1 = mild, 2 = moderate, 3 = severe); Discharge (0 = none, 1 = mild, wets ½ × ½ cm gauze piece, 2 = moderate, wets 1 × 1 cm gauze piece, 3 = severe, wets >1 cm gauze piece); Induration (0 = absent, 1 = present with hardness in peri-track or peri-anal area); Inflammation (0 = absent, 1 = slight redness, tenderness, and painful movement); External Opening (0 = not dry, 1 = dry); Healing Status (0 = not healed, 1 = healed).

Effect of Pain

Group A exhibited significant pain reduction from 100% grade 3 pain on day 15 to 100% grade 0 pain by day 120. Group B showed a more gradual improvement, with residual grade 1 (4.5%) persisting in some cases by day 120. Inter-group differences were statistically significant at most time points (p < 0.05), except on days 45 and 90.

Srava (Wound Discharge)

Both groups demonstrated significant reductions in discharge. By day 90, all participants in Group A and Group B achieved 100% grade 0 discharge, but a relapse in Group B (22.7% grade 1 discharge) by day 120 was significant (p = 0.009). Inter-group differences were notable at days 30 (p = 0.015) and 120.

Induration

Both groups showed a gradual decline in induration, with Group A reaching 100% grade 0 induration by day 60. In Group B, some residual induration (4.5% grade 1) persisted up to day 120. However, inter-group differences were not statistically significant throughout the study.

Inflammation

Group A achieved complete resolution of inflammation (100% grade 0) by day 60, whereas Group B had minor residual inflammation (4.5% grade 1) by day 120. No significant inter-group differences were observed at any time point.

External Opening Dryness

Both groups initially had 100% grade 0 dryness. By day 45, Group B maintained this status, whereas Group A had a significant drop (p = 0.008). At day 60, Group A transitioned to 100% grade 1 dryness compared to Group B (63.6% grade 0). Differences were statistically significant on days 45, 60, and 120 (p < 0.05).

Healing Status of Fistulous Tract

By day 90, 59.1% of Group A achieved grade 0 healing, compared to none in Group B (p = 0.001). Group A demonstrated complete healing by day 120, while 27.3% of Group B still exhibited grade 0 healing (p = 0.008).

Recurrence

Group A had no recurrences by day 120, while Group B experienced a 27.3% recurrence rate (p = 0.000), indicating a significant advantage for Group A.

Hospital Stay

Group A had shorter hospital stays, with 59.1% staying 5 days and 18.2% staying 6 days. In contrast, Group B had longer stayed, with 45.5% staying 3 days and 40.9% staying 1 day. Group A's higher duration reflects surgical recovery nuances.

In summary, Group A showed faster and more consistent recovery with statistically significant outcomes across multiple parameters, indicating greater efficacy in treatment and long-term outcomes compared to Group B.

Discussion

Anal fistulas are common and challenging to treat, often leading to significant patient frustration due to high recurrence rates and complications such as incontinence. Recurrence is frequently caused by missed sidetracks, chronic disease at the internal entrance, and insufficient intersphincteric drainage. Effective primary surgery involves abscess drainage, intersphincteric drainage, and excision of secondary tracks. Surgical intervention remains the only effective treatment, but frequent recurrences, failed surgeries, and complications like deformity contribute to considerable emotional distress in patients, with some developing anxiety, depression, etc.

In Ayurveda, fistula-in-ano, or “Bhagandara,” has been documented since ancient times by Sushruta, who described various approaches for treatment, including surgical, parasurgical, and conservative methods. Sushruta's definition of Bhagandara aligns closely with modern understanding, highlighting the disease's nature: branching tracks through the perineum affecting organs such as the anorectum, bladder, and genitalia, causing structural damage.[21]

Ayurveda's etiopathogenesis of Bhagandara also identifies contributing factors such as prolonged sitting, constipation, and injuries to the anal area, with the disease typically following the formation of an abscess (bhagandara pidika).[22] Modern clinical practice often references three main classification systems for fistulas: Parks' classification, Goodsall and Miles' classification, etc. Additionally, Ayurvedic texts describe varieties of Bhagandara based on doshas and injury patterns, with names such as Ushtragreeva (trans-sphincteric, camel-neck-shaped tracks) and Riju (straight tracks).[7] [23]

Ayurvedic texts recommend excision (fistulectomy) or laying open the fistula tract (fistulotomy) for treating Bhagandara.[24] Charaka gave only a brief but systematic account of treatment. A perfectly followed sequence of preoperative bowel preparation (virechana), probing (eshana), and laying open of track (paatana) followed by cauterization (taildaha) to prevent recurrence and the post-operative wound management described briefly by Charaka is also followed in today's practice in the same way.[25]

We can see that the use of ksharasutra therapy was recommended by all major classics but the method of preparation of ksharasutra was not revealed until the period of Chakradutta i.e. 12th century AD who prepared it by repeated coatings of latex of Euphorbia neriifolia (snuhi ksheera) and powder of Curcuma longa (haridra) over a thread.[26] Sadanand Sharma elaborated upon the same method in the 20th century and defined the number of coatings to be seven.[27]

Despite so many descriptions of ksharasutra therapy available in the texts of ancient to modern periods, the practice was not prevalent until its revival in the 1960s by the efforts of the scholarly surgeons of the Banaras Hindu University like Dr. PS Shankaran, Prof. PJ Deshpande, Prof. KR Sharma, and others. They standardized the preparation of ksharasutra after several hits and trials and started using it as the primary modality for the treatment of all types of fistulas. The standard ksharasutra used initially was prepared by 21 coatings of the latex of Euphorbia neriifolia (snuhi), the alkaline part of the ash (kshara) of Achyranthes aspera (apamarga), and the powder of Curcuma longa (haridra) over the thread.

IFTAK (Interception of Fistulous Tract with Application of Ksharasutra) is also called the “window technique” of ksharasutra therapy. Meanwhile, laser treatment for fistula-in-ano, specifically FiLaC (fistula laser closure) or LAFT (Laser Ablation of Fistula Tract), has gained popularity as a “sphincter-saving approach”.[28] LAFT involves applying 360° laser energy to the fistula tract using a radial fiber, thus preserving sphincter integrity.

In a study by Haluk Tümer, and Guney Cem Bulbuloglu in 2023, The recurrence rate in the laser group was found to be statistically significantly higher compared to the fistulotomy group (p < 0.05)[29]

Various techniques have been developed for treating complex anorectal fistulas, each with distinct methods and outcomes. The LIFT procedure involves locating and ligating the fistula tract in the intersphincteric space. A meta-analysis of 1,378 LIFT cases found a 76% success rate, 14% complication rate, and a 1.4% fecal incontinence rate.[30] [31] The Endorectal Advancement Flap technique cures the fistula tract and uses a segment of the rectum to cover the internal opening, with healing rates of 66% to 87%. However, it may cause incontinence if the internal anal sphincter muscles are involved, especially with partial-thickness flaps; full-thickness flaps generally heal more reliably.[32] [33] [34] [35] [36] [37] [38] [39] The Fibrin Plug Technique, which uses a collagen matrix to fill the fistula tract, has a relatively low long-term healing rate, typically around 50% or less.[40] [41] Autologous adipose tissue injection has shown some success, with a study of 77 patients reporting a 51% healing rate after six months and a 12% reduction in anal discomfort, although this technique requires specialized equipment.[42] Stem cell therapy has also shown promise; in a phase 1 clinical trial involving 20 patients with non-Crohn's anorectal fistulas, 69% of patients achieved complete closure, though 15% developed perianal abscesses. Results from phase 3 trials for Crohn's patients are still awaited.[43] [44] Another option, the TROPIS (Trans-Anal Opening of Intersphincteric Tract) procedure, was introduced in 2017 for complex fistulas and involves opening the fistula tract from the internal to the external sphincter. This technique reported a 90% healing rate in initial studies.[45] Finally, the PERFECT (Proximal Superficial Cauterization of Mucosa at Internal Opening) method involves curettage and cauterization at the internal opening to facilitate healing by secondary intention, achieving a 79.5% success rate with a 20.5% recurrence in a study of 51 complex cases.[46] The choice of treatment depends on the complexity and location of the fistula, as well as patient-specific factors, with each technique offering unique advantages and potential risks.

Surgical goals for anal fistula treatment include fistula closure, minimal complications, continence preservation, and preventing recurrence while allowing a quick return to normal activities. However, no single treatment achieves all these aims, and recurrence and incontinence remain significant challenges. This study assesses the effectiveness of IFTAK and LAFT in managing trans-sphincteric fistula-in-ano, or Bhagandara.

Conclusion

The study compares the effectiveness of the IFTAK (Interception of Fistula Tract and Application of Ksharsutra) and LAFT (Laser Ablation of Fistula Tract) techniques for managing trans-sphincteric fistula in ano. The findings suggest that the IFTAK technique is more effective, showing no recurrences and better healing rates, especially for posterior trans-sphincteric fistulas. It is a minimally invasive procedure that provides high success rates, fewer complications, and better patient satisfaction compared to LAFT. However, it does involve more pain and discharge and requires a skilled surgeon due to its blind nature.

The LAFT technique, while offering less pain and discharge and a shorter hospital stay, has a higher recurrence rate and is more effective for anterior trans-sphincteric fistulas. It also requires experienced surgeons and is more expensive than IFTAK.

Both procedures are effective, but IFTAK generally offers better outcomes, particularly for posterior fistulas. The study recommends further research on a larger sample and suggests combining IFTAK and LAFT techniques for potentially enhanced results in treating fistulas. The proposed combined technique involves using IFTAK for tract interception followed by laser ablation for distal tract treatment, combining the benefits of both approaches.

Conflict of Interest

The authors declare there are no conflicts of interest related to this study.

Authors' Contribution

AKP: Conceptualization, Validation, Resources, Writing – review & editing, Supervision. AP: Conceptualization, Data curation, Writing – original draft SP: Writing – original draft, Data curation NH: Writing – review & editing, Data curation AKT: Writing – review & editing, Visualization. AKD: Writing – review & editing, Supervision.

• References

• 1 Madoff Robert D, Melton-Meax Genevieve B. 136. Diseases of the rectum and anus: Anal fistula. In: Goldman Lee, Schafer Andrew I. editors. Goldman-Cecil medicine. 26th ed. vol. 1.. Philadelphia: Elsevier; 2020: 935 [ISBN 978–0-323–55087–1.]
• 2 Parks AG. Pathogenesis and treatment of fistuila-in-ano. BMJ 1961; 1 (5224) 463-469
• 3 Steele SR, Hull TL, Hyman N, Maykel JA, Read TE, Whitlow CB. The ASCRS textbook of colon and rectal surgery. 4th ed.. 2022
• 4 Eglinton TW, Barclay ML, Gearry RB, Frizelle FA. The spectrum of perianal Crohn's disease in a population-based cohort. Dis Colon Rectum 2012; 55 (07) 773-777
• 5 Makowiec F, Laniado M, Jehle EC, Claussen CD, Starlinger M. Magnetic resonance imaging in perianal Crohn's disease. Inflamm Bowel Dis 1995; 1 (04) 256-265
• 6 Milligan ETC, Morgan CN. Surgical anatomy of the anal canal. Lancet 1934; 224 (5804) 1150-1156
• 7 Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg 1976; 63 (01) 1-12
• 8 Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas and its implications for patient management. Radiographics 2000; 20 (03) 623-635 , discussion 635–637
• 9 Garg P. Comparing existing classifications of fistula-in-ano in 440 operated patients: Is it time for a new classification? A Retrospective Cohort Study. Int J Surg 2017; 42: 34-40
• 10 A k Attri, Sanjay Gupta, et al. A manual on fistula in ano and ksharsutra therapy, Management of Fistula in ano (Current Practices); 2015:95
• 11 Jivapaisarnpong P. Core out fistulectomy, anal sphincter reconstruction and primary repair of internal opening in the treatment of complex anal fistula. J Med Assoc Thai 2009; 92 (05) 638-642
• 12 Anal fistula principles and management. Springer
• 13 Panigrahi HK, Rani R, Padhi MM, Lavekar GS. Clinical Evaluation of Kshara sutra Therapy in the management of Bhagandara( Fistula- in-Ano)- A prospective study. Anc Sci Life 2009; 28 (03) 29-35
• 14 Koehler A, Risse-Schaaf A, Athanasiadis S. Treatment for horseshoe fistulas-in-ano with primary closure of the internal fistula opening: a clinical and manometric study. Dis Colon Rectum 2004; 47 (11) 1874-1882
• 15 Champagne BJ, O'Connor LM, Ferguson M, Orangio GR, Schertzer ME, Armstrong DN. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum 2006; 49 (12) 1817-1821
• 16 Schwandner O. Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn's disease. Tech Coloproctol 2013; 17 (02) 221-225
• 17 Van Onkelen RS, Gosselink MP, Schouten WR. Ligation of intersphincteric fistula tract in low transsphincteric fistulas: a new technique to avoid fistulotomy. Colorectal Dis 2013; 15 (05) 587-591
• 18 Srivastav P, Sahu M. et.al. 2010
• 19 Sahu M, Singh M. Interception of fistula track with application of ksharsutra (IFTAK) in the management of fistula-in-ano. In: Sahu M. editor. A manual on fistula-in-ano and ksharsutra therapy. Varanasi: National Resource Center on Ksharsutra therapy, Department of Shalya Tantra, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University; 2015: 184-220
• 20 Giamundo P, Esercizio L, Geraci M, Tibaldi L, Valente M. Fistula-tract Laser Closure (FiLaC™): long-term results and new operative strategies. Tech Coloproctol 2015; 19 (08) 449-453
• 21 Shastri AD. Ed. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Nidana Sthana: Chapter 4, Verse 3. Reprint ed.. Varanasi: Chaukhamba Sanskrit Sansthan; 2009: 317
• 22 Gupta AD. Ed. Vidyotini Hindi Commentary on Ashtanga Hridayam of Vagbhata, Uttara Sthana: Chapter 28, Verse 1–2. Reprint ed.. Varanasi: Chaukhambha Prakashan; 2011: 750
• 23 Gupta AD. Hindi Commentary on Ashtanga Samgraha of Vagbhata, Uttara Sthana: Chapter 33, Verse 10, 17. Reprint ed.. Varanasi: Krishnadas Academy; 2002: 313
• 24 Shastri AD. Ed. Ayurveda Tattva Sandeepika Hindi commentary on Sushruta Samhita of Sushruta, Sootra Sthana: Chapter 25, Verse 3. Reprint ed.. Varanasi: Chaukhamba Sanskrit Sansthan; 2009: 134
• 25 Shastri KN, Chaturvedi GN. Vidyotini Hindi Commentary on Charaka Samhita of Agnivesha, Chikitsa Sthana: Chapter 12, Verse 97. Reprint ed.. Varanasi: Chowkhambha Bharti Academy; 2007: 378
• 26 Vajpeyee JS. Subodhini Hindi Commentary of Chakradatta of Sri Chakrapanidatta: Chapter 5, Verse 148. 3rd ed.. Bombay: Shri Laxmi Venkateshwar Steam Press; 1941: 55
• 27 Shastri KN. Ed. Rasa Tarangini of Sri Sadanand Sharma: Tarang 24, Verse 527–530. 11th ed. Reprint.. New Delhi: Motilal Banarasidas; 2014: 745-746
• 28 Giamundo P. Laser treatment for anal fistulas: what are the pitfalls?. Tech Coloproctol 2020; 24 (07) 663-665
• 29 Tümer H, Bulbuloglu GC. A Comparison of Laser and Fistulotomy Techniques in the Treatment of Fistula-in-Ano. Cureus 2023; 15 (04) e37053
• 30 Emile SH, Khan SM, Adejumo A, Koroye O. Ligation of intersphincteric fistula tract (LIFT) in treatment of anal fistula: An updated systematic review, meta-analysis, and meta-regression of the predictors of failure. Surgery 2020; 167 (02) 484-492
• 31 Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K. Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai 2007; 90 (03) 581-586
• 32 Jarrar A, Church J. Advancement flap repair: a good option for complex anorectal fistulas. Dis Colon Rectum 2011; 54 (12) 1537-1541
• 33 Mitalas LE, Dwarkasing RS, Verhaaren R, Zimmerman DD, Schouten WR. Is the outcome of transanal advancement flap repair affected by the complexity of high transsphincteric fistulas?. Dis Colon Rectum 2011; 54 (07) 857-862
• 34 Madbouly KM, El Shazly W, Abbas KS, Hussein AM. Ligation of intersphincteric fistula tract versus mucosal advancement flap in patients with high transsphincteric fistula-in-ano: a prospective randomized trial. Dis Colon Rectum 2014; 57 (10) 1202-1208
• 35 Sonoda T, Hull T, Piedmonte MR, Fazio VW. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum 2002; 45 (12) 1622-1628
• 36 Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn's fistula-in-ano. Dis Colon Rectum 2010; 53 (04) 486-495
• 37 Balciscueta Z, Uribe N, Balciscueta I, Andreu-Ballester JC, García-Granero E. Rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis. Int J Colorectal Dis 2017; 32 (05) 599-609
• 38 Balciscueta Z, Uribe N, Mínguez M, García-Granero E. The changes in resting anal pressure after performing full-thickness rectal advancement flaps. Am J Surg 2017; 214 (03) 428-431
• 39 Dubsky PC, Stift A, Friedl J, Teleky B, Herbst F. Endorectal advancement flaps in the treatment of high anal fistula of cryptoglandular origin: full-thickness vs. mucosal-rectum flaps. Dis Colon Rectum 2008; 51 (06) 852-857
• 40 El-Gazzaz G, Zutshi M, Hull T. A retrospective review of chronic anal fistulae treated by anal fistulae plug. Colorectal Dis 2010; 12 (05) 442-447
• 41 Kontovounisios C, Tekkis P, Tan E, Rasheed S, Darzi A, Wexner SD. Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review. Colorectal Dis 2016; 18 (05) 441-458
• 42 Dalby HR, Dige A, Pedersen BG. et al. Efficacy of injection of freshly collected autologous adipose tissue into complex cryptoglandular anal fistulas. Dis Colon Rectum 2023; 66 (03) 443-450
• 43 Gottesman L. Stem cells in non-Crohn's anorectal fistula. Dis Colon Rectum 2021; 64 (11) e669
• 44 Garcia-Olmo D, Gilaberte I, Binek M. et al. Follow-up study to evaluate the long-term safety and efficacy of Darvadstrocel (mesenchymal stem cell treatment) in patients with perianal Fistulizing Crohn's disease: ADMIRE-CD phase 3 randomized controlled trial. Dis Colon Rectum 2022; 65 (05) 713-720
• 45 Garg P. Transanal opening of intersphincteric space (TROPIS) - A new procedure to treat high complex anal fistula. Int J Surg 2017; 40: 130-134
• 46 Garg P, Garg M. PERFACT procedure: a new concept to treat highly complex anal fistula. World J Gastroenterol 2015; 21 (13) 4020-4029

Publication History

Received: 06 December 2024

Accepted: 05 February 2025

Article published online:
20 March 2025