sepsis510dd.com

PradeepCHOWBEYRajeshKHULLAR,AnilSHARMAVandanaSONI,ManishBAIJALVIDEO-ASSISTEDANALFISTULATREATMENT(VAAFT)Lefttoright:Dr.
AnilSharma,Dr.
VandanaSoni,Dr.
PradeepChowbey(Director),Dr.
RajeshKhullar,Dr.
ManishBaijal.
TheMaxInstituteofMinimalAccess,MetabolicandBariatricSurgery(MAMBS),thefirstofitskindintheAsiaPacificsubcontinent,hasbeenexpandingthehorizonsofMinimalAccessSurgeryforovertwodecades.
Theinstitutehasbeenawardedthespecialtitle'Founder'andaccreditedasanInternationalCentreofExcellenceforBariatricSurgeryandHerniaSurgerybytheSurgicalReviewCorporation(SRC),USA.
AllConsultantsattheinstitutehavebeenaccreditedasSurgeonsofExcellencebySRC.
Theinstituteisequippedwithstate-of-the-arttechnologyandinfrastructuretoprovidequalityservicesinMinimalAccess,MetabolicandBariatricSurgery.
Academicsandtrainingprogrammesareoneoftheforemostprioritiesattheinstitute.
Addressforcorrespondence:Dr.
AnilSharmaMS(Bom),FICS,FRCS(Edin)MaxInstituteofMinimalAccess,MetabolicandBariatricSurgeryMaxSuperSpecialtyHospital–EastBlock2,PressEnclaveRoad,Saket,NewDelhi–110017(India)Phone(off):+91-9999668200/99996628700,Fax:+91-11-66115585E-mail:asharma736@yahoo.
in/anil.
sharma@maxhealthcare.
comWeb:www.
maxhealthcare.
comVIDEO-ASSISTEDANALFISTULATREATMENT(VAAFT)PradeepCHOWBEY,DirectorRajeshKHULLARAnilSHARMAConsultantConsultantVandanaSONIManishBAIJALConsultantConsultantMaxInstituteofMinimalAccess,MetabolicandBariatricSurgeryMaxSuperSpecialtyHospital,NewDelhi,IndiaPrefaceItisagreatpleasureformetointroducethismanualontheVAAFTtechnique,editedbyProf.
PradeepChowbey,withwhomIshareabothcordialandprofessionalrelationship.
Fortunately,inthelastfewyears,avarietyofminimally-invasivetechniqueshavebeenproposedinordertofurtherimprovetheoutcomesofsurgeryinthefieldofcomplexanalfistulas.
Nowadays,lessandlessinvasivetechniquesareemployedtocurecomplexanalfistulasandrecurrences,withincreasinglywidespreaduseofanalsphincter-savingtechniquesasmethodoffirstchoice.
ThemainbenefitthatVideo-AssistedAnalFistulaTreatment(VAAFT)possessesovertheothertechniques,isthedirectvision.
Weallknowthat,evenrecently,manypapershavebeenpublishedabouttraditionaltechniqueslikelayopen,setonplacement,fistulectomy,etc.
,reportingon30%offlatusincontinence,4–5%softstoolsandevensolidstools,andthatsomepatientsareobligedtouseapad.
Thisistherightoccasiontorememberourpatientssufferingfromanalfistulas.
Theyareentrustedinourcareanddeservetobetreatedasiftheywereourownchildren.
WhichtechniquewouldwewanttobeperformedonthemWouldwereallywanttoruntheriskofanykindofincontinenceThisfundamentalideawasimmediatelyunderstoodbyProfessorPradeepChowbeyandhisstaff.
ImethimforthefirsttimeinSantaMargheritaLigure,Italy,ontheoccasionofoneofourinternationalVAAFTcourses,andstraightaway,webothunderstoodtheimportanceofourmutualcooperation.
In2011,IhadthespecialhonourtoinaugurateProfessorChowbey'sprestigiousDepartmentofProctologyattheMaxInstitute,NewDelhi.
Ihavepersonallywitnessedhishighlevelofprofessionalismandadvancedskills,notonlyinthefieldofbariatricsurgery,butalsoinothersurgicalspecialties.
Inordertoprovideevidence,itissufficienttoreadthismanualandonewillrealizethetruedimensionoftheoutstandingworkofProf.
Chowbeyandhisstaff.
IalsowanttoexpressmycordialgratitudetohimandhisstaffforspreadingtheVAAFTtechniquealloverIndiawhiletakingcareoftheirpatientsinthebestpossibleway.
SincerethanksalsogotothemembersofProf.
Chowbey'sstaff,DrSharma,DrSoni,DrKhullarandDrBaijal.
AllourstaffcongratulatesthemfortheirvaluableworkandIpersonallywishthemeveryfuturesuccess.
Prof.
PiercarloMeinero6AcknowledgementGratefulacknowledgementtoDr.
KhoobsuratNajma,MedicalWriteratMaxInstituteofMinimalAccess,MetabolicandBariatricSurgery,forconceptualizing,compilingandeditingthescientificcontentofthismanuscript.
TheauthorsarethankfultoMs.
TriptaSharma,Mr.
AnshulChauhan,MrPankajGuptaandMs.
AenuBatrafortechnicalassistanceandsecretarialsupport.
Pleasenote:AttachedtotheinsidebackcoverisaDVDKS774titled"Video-AssistedAnalFistulaTreatment(VAAFT)",producedbyProf.
PradeepChowbeyandcollaborators.
Video-AssistedAnalFistulaTreatment(VAAFT)PradeepChowbey,Director,RajeshKhullar,Consultant,AnilSharma,Consultant,VandanaSoni,Consultant,ManishBaijal,ConsultantMaxInstituteofMinimalAccess,MetabolicandBariatricSurgery,MaxSuperSpecialtyHospital,NewDelhi,IndiaCorrespondenceaddressoftheauthor:Dr.
AnilSharma,MS(Bom),FICS,FRCS(Edin)MaxInstituteofMinimalAccess,MetabolicandBariatricSurgery,MaxSuperSpecialtyHospital–EastBlock2,PressEnclaveRoad,Saket,NewDelhi–110017,IndiaPhone(off):+91-9999668200/9999668700Fax:+91-11-66115585E-mail:asharma736@yahoo.
inanil.
sharma@maxhealthcare.
comWeb:www.
maxhealthcare.
comAllrightsreserved.
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7TableofContentsClassificationofAnalFistulae8PatientSelection9Indications9Contraindications9Equipment9Fistuloscope10VideoEquipment10OperatingTechnique10OperatingRoomSetupandPatientPositioning10PreparationandAssemblyofInstruments10InitialDiagnosticAssessment11SurgicalProcedure11LocalizationoftheInternalOpening12ExaminationandFulgurationoftheFistulaTrack14ClosureoftheInternalOpening16PostoperativeCare17Discussion17References18VAAFTInstrumentSetforVideo-AssistedAnalFistulaTreatmentIMAGE1SCameraSystemandAccessories2081ClassificationofanalfistulaeaccordingtoParks.
10Intersphincteric(A),Transsphincteric(B),Suprasphincteric(C),Extrasphincteric(D).
InternalanalsphincterExternalanalsphincterLevatoraniAnalcanalClassificationofAnalFistulaeVariousclassificationsforanalfistulaehavebeenproposedoverseveraldecades.
MilliganandMorgan,in1934,classifiedanalfistulaeonthebasisoftherelationofthefistuloustracktotheanorectalring.
7Theyweresubdividedintoanalandanorectalfistulae,dependingonthelocationbeloworabovetheleveloftheanorectalring.
Stelzner,in1959,classifiedanalfistulaeintothreemaintypes:intermuscular,transsphinctericandextrasphincteric,inrelationtotheexternalanalsphincter.
17GolighermodifiedtheclassificationofMilliganandMorganbysubdividinghighanorectalfistulaeintoischiorectalorinfralevatorandpelvirectalorsupralevator.
3Thompsonclassifiedanalfistulaeonthebasisoffrequencyandeaseofoperationintosimpleandcomplexanalfistulae.
18Lilius,in1968,classifiedanalfistulaeasseenduringtheoperativeprocedureinto:subcutaneous,lowintermuscular,highintermuscular,lowanal,highanalandpelvirectal.
5IntroductionAnanalfistulaisdefinedasatracklinedwithgranulationtissue.
Thetrackconnectsaprimaryopeninginsidetheanalcanaltoasecondaryopeningintheperianalskin.
Theoverallprevalenceofanalfistulais8–10casesper100,000individualswithamale:femaleratioof2:1.
Analfistulacanhaveaprimaryetiology,resultingfromananorectalabscessorcandevelopsecondarytotrauma,tuberculosis,Crohn'sdisease,analfissures,certaininfections(actinomycosis,chlamydia,HIV),carcinomasandexposuretoradiation.
Anorectalabscesscanbecomplicatedbyanalfistulainabout25%ofpatientsduringtheacutephaseofsepsisorwithin6monthsthereafter.
Amongthetreatmentoptionsavailableforanalfistulae,therearebothtraditionalandnoveltechniques.
Thetraditionalmethodsincludefistulotomy(layingopenofthetrack)andfistulectomy(excisionoftheentiretrack)forlowfistulae.
Forhighandcomplexfistulae,setonplacementistraditionallythepreferredtreatmentmodalityusedtominimizeincontinence.
Morecomplexsurgicalproceduresintheformoflocaladvancementflapshavemetwithmoderatesuccess.
Thenewertreatmentoptionsincludeuseoffibringlue,bio-prostheticplugsandligationofintersphinctericfistulatract(LIFT).
Traditionaltechniquesincludingfistulectomyanduseofcuttingsetonhavebeenassociatedwithincontinence,especiallyinpatientswhohavehadprevioussurgery4.
Mucosaladvancementflapsaretechnicallychallengingandarefoundtohavehighratesofrecurrenceandpostoperativeincontinence.
1,8,9,11,14,16.
TheLIFTprocedurehasprovedtobeassociatedwithgoodhealingrates.
2,12,13,15Inrecentyears,aminimallyinvasivevideo-assistedtechniquehasemergedusingaspeciallydesignedfistuloscope.
6TheVideo-AssistedAnalFistulaTreatment(VAAFT)wasdevelopedbyProfessorP.
Meineroin2006.
6Thetechniqueinvolvestheidentificationandsecureinternalclosureoftheinternalfistulaopeningandvisualizationwithcauterizationofthefistuloustrackusingaspeciallydesignedfistuloscope.
WeadoptedthetechniqueinApril2011inanefforttoreducepostoperativemorbidityandtoenableourpatientstobenefitfromtheadvantagesofminimallyinvasivesurgery.
BetweenApril2011andDecember2012,VAAFTwasperformedin416patientsatourDivisionofProctologyattheMaxInstituteofMinimalAccess,MetabolicandBariatricSurgery,NewDelhi,India.
Thebrochurereflectsourexperiencewiththenewtechniqueoverthisperiod.
ThemostwidelyusedclassificationforanalfistulaewasformulatedbyParksin1976.
10TheParksclassificationrelatesthetypeoffistulatotheexternalanalsphincter/puborectaliscomplex.
AccordingtoParks'classification,analfistulaeareclassifiedintofourmaintypes(Fig.
1).
Theseinclude:IntersphintericfistulaTranssphinctericfistulaSuprasphinctericfistulaExtrasphinctericfistulaIntersphinctericfistulaisthemostcommonanalfistulawhichpredominantlyarisesfromaninfectionwithinananalgland,thattracksdowntowardstheanalmargin.
Here,thefistulatrackismainlyconfinedtotheintersphinctericplane.
Atrans-sphinctericfistulaconnectstheintersphinctericplanewiththeischiorectalfossabyperforatingtheexternalsphinctermuscle.
Asuprasphinctericfistulapassesabovetheexternalsphinctermuscleandperforatesthelevatorani.
Anextrasphinctericfistulapassesfromtherectumtotheperianalskin,completelyexternaltothesphincterapparatus.
ABCD9Analfistulaecanalsobeclinicallyclassifiedassimpleandcomplexanalfistula.
Asimpleanalfistulaconsistsofasingletractthatinvolves30–50%ofexternalanalsphincters,arefoundinananteriorlocation,andmayberelatedtoanetiologyofradiationexposureandinflammatoryboweldisease.
Complexfistulaecanbefoundinpatientswithalreadycompromisedsphincterfunction(pronetoincontinence).
Thesecomplexfistulaecommonlyrequireastagedprocedurewhereinthefirststepistocontrolsepsisbysetonplacement.
Preoperativemagneticresonanaceimaging(MRI),appliedasanadjunctmodalityindiagnosticworkupandtreatmentplanning,hasshowntobeveryusefulinachievinganoptimaloutcomeofthisnewsurgicaltechnique.
MRIiscommonlyusedduringinitialdiagnosticassessmentandtreatmentplanningfor:Identificationoftheprimaryfistuloustractaswellasitssecondaryramifications.
Identificationofassociatedabscesses.
Identificationofthetypeoffistula.
Detectionofinflammatoryswellingsorfibrosis.
Demonstrationofoccultintersphinctericspacesepsis.
Assessmentoflong-termoutcomes.
PatientSelectionIndicationsAlldischargingfistulae,whichinclude:Maturefistula.
Mediumtohighfistulawithwell-formedsingleormultipletracks.
Complexfistula(recurrentfistula,horseshoefistula).
ContraindicationsSubmucousfistula.
Lowperianalfistula.
Fistulawithacute/recentinflammation(immaturetrack).
Pelvicfistula(diagnosedbyMRI)Noactivedischargeforatleast2months.
Fistulasecondarytosystemicpathologies(Crohn'sdisease,tuberculosis,actinomycosis,postirradiation,malignancy).
EquipmentUseofdedicatedequipmentishighlyrecommended(KARLSTORZTuttlingen,Germany).
Theinstrumentsetessentiallycomprisesthefollowingcomponents(Fig.
2):Fistuloscope()3-mmForceps()Endobrush()UnipolarElectrode()Inaddition,thesurgeonwillrequireAnoscope()LinearEndostapler()Glycine-mannitol1%solutionVolkmannSpoon()210FistuloscopeThefistuloscopeoffersan8°directionofviewandhasastraightworkingchannelalsousedasirrigationchannel.
Theoperativelengthis18cmandtheouterdiameteris3.
3x4.
7mm(Fig.
3).
VideoEquipmentWeuseastandardhighdefinition(HD)technologyforourvideoequipment(Fig.
4).
(IMAGE1HD,KARLSTORZTuttlingen,Germany).
TheseendoscopiccamerasystemsareequippedwiththreeCCDchipsthatsupportthe16:9inputformatandcaptureimageswitharesolutionof1920x1080pixels(Fig.
5).
3Fistuloscope(KARLSTORZTuttlingen,Germany).
4VideoequipmentintheOR.
5High-definitionvideocamera.
OperatingTechniqueOperatingRoomSetupandPatientPositioningThepatientisplacedinalithotomypositionwith15°–20°Trendelenburgtilt,asshowninFig.
6.
Theprocedureisperformedunderspinal/generalanesthesia.
PreparationandAssemblyofInstrumentsOncethepresenceofasubcutaneousfistulahasbeenexcluded,adecisiontoproceedwithVAAFTistaken.
Thefistuloscopeisconnectedtothecoldlightsourceandloadedwiththeobturator.
TheirrigationtubingwhichisconnectedtoabagcontainingGlycine-Mannitol1%solution,isattachedtotheLUERinletofthefistuloscope(Fig.
7).
6Patientpositioningandoperatingroomsetup.
7InstrumentsetforVideo-AssistedAnalFistulaTreatment(VAAFT).
11InitialDiagnosticAssessmentTheinitialdiagnosticassessmentinvolvesexaminationofperianalareaandtheperineumforexternalfistulaopenings(Fig.
8).
Digitalperrectalexaminationandproctoscopyisperformedtoassessanorectalpathologyandtolocalizethesiteoftheinternalopeningofthefistula.
SurgicalProcedureTheexternalopeningofthefistulaisdilatedwiththetipofafistulaprobe,ifrequired(Fig.
9).
Fibrousscartissueisexcisedtoenlargetheopeninginordertoallowentryofthefistuloscope(Fig.
10).
Priortoinsertingthefistuloscope,thetipisplacedjustwithintheexternalopeningandtheLUERstopcockisopenedallowingtheglycine-mannitol1%solutiontodistendanddelineatethefistulatrack(Fig.
11).
8Openingofexternalfistula.
9Initialdilationoftheexternalfistulaopening.
10Fibrousscartissueisexcisedtoenlargetheexternalfistulaopening.
11Thefistuloscopeisinsertedthroughtheexternalfistulaopening.
12LocalizationoftheInternalOpeningThefistuloscopeisgentlyadvancedthroughthefistulatractwhichisdistendedbytheirrigationsolution(Fig.
12).
Thefistuloscopeisslowlyadvancedwithside-to-side,rotatoryorverticalmovementsasmayberequired.
Theoperativemaneuversareguidedonthebasisofthereal-timeimageonthevideomonitorlocatedattheheadendofthepatient.
Atypicalfistulatractappearsasatunnelwithgranulationtissueandfibroustissueintheformofwhitishflakesappearingwithinthefistulatract(Figs.
13a–c).
Atthisstage,anattemptismadetolocatethepositionoftheinternalfistulaopening.
Ananalretractorisinsertedtolocalizethepositionoftheinternalopening.
Inmanyinstances,ajetofirrigatingsolutionisseenspurtingfromtheinternalopeningfromwithintheanalcanal(Fig.
14).
Insomepatientswithawell-definedfistulatractandlargeinternalopening,thefistuloscopeitselfmayexitthroughtheinternalopeningintotheanalcanal.
Inotherpatients,theinternalopeningmaybeobliteratedorconcealedwithinafoldofmucosa.
Inthesepatients,thetransilluminationeffectofthe12Thefistuloscopeisadvancedwhiledistendingthefistulatrackwithirrigationsolution.
13Endoscopicaspectsofthefistulatrack(a,b).
Fistulatrackwithfibroustissue(c).
cba14Jetofirrigationfluidspurtingfromtheinternalopening.
1316Staysuturesareplacedthroughtheanalmucosatomarktheinternalopening.
1815Transilluminationeffectduetothelightofthefistuloscopeshiningthroughthenearbyinternalopening.
1719lightofthefistuloscopeshiningthroughthebowelwall(withthelightsoftheORswitchedoff)mayprovideacluetothelocationoftheinternalopening(Fig.
15).
Provided,theinternalopeningcannotbeidentified,noattemptshouldbemadetocreateanartificialinternalopening.
Oncetheinternalopeningofthefistulahasbeenlocalizedonthebowelwall,itisisolatedandmarkedwith3staysutures.
Thesuturesareplacedthroughthefullthicknessoftherectalmucosa(Figs.
16–19).
Thefirstsutureisplaceddistaltotheopening,thesecondattheopeningandthethirdproximaltotheinternalopening.
Thetailsofthesuturesarekeptlongandareheldbymeansofanarteryforcepsoutsidetheanalcanal.
14ExaminationandFulgurationoftheFistulaTrackOncetheinternalopeninghasbeenlocalizedandisolatedwithstaysutures,theentirefistulatractisexaminedforsecondaryfistuloustracksandabscesscavities.
Thefistuloustractisre-examinedwiththefistuloscopestartingattheexternalopening.
Thefistuloscopeisadvancedtosearchforanysecondarytracksandabscesscavities(Figs.
20a–b).
Anyabscesscavitiesthatareidentifiedshouldbedrained,followedbyfulgurationoftheirwalls.
Secondarytracks,ifpresent,areenteredwiththefistuloscopeandgranulationtissueonthewallsisfulgurated.
Theentireliningofthefistulatractisfulgurated.
Fulgurationiscarriedoutbymeansofflexiblemonopolarelectrodethatispassedthroughtheworkingchannelofthefistuloscope(Figs.
20c–g).
20fed20g20Multiplefistulatracks(a).
Fistulatracksshowingabscesscavities(b).
Fulgurationoffistulatrack(c–g).
cba1521Endobrushbeingintroducedthroughtheworkingchanneloffistuloscope.
22Endoscopicviewoftheendobrush'stip.
23Debridementwithanendobrush.
24DebridementwithaVolkmannspoon.
Debridementiscompletedwiththehelpofanendobrush(passedthroughthefistuloscope,Figs.
21–23)andwithaVolkmannspoon(afterremovalofthefistuloscope,Fig.
24).
Excisedtissueissentforhistopathologicalexamination.
16ClosureoftheInternalOpeningTheanalretractorisre-inserted,thusaffordingagoodviewoftheinternalopeningwithstaysutures.
Tractionisappliedonstaysuturesperpendiculartothebowelwallandalinearendostapler(whitecartridge)isappliedatthebase(Fig.
25a).
Thisensuresasecurestapledclosureofinternalopening(Figs.
25b,c).
Thestaplelineisinspectedforhaemostasis(Fig.
25d).
Atemporarydressingisappliedtotheexternalopening.
25Preparationforstaplingtheanalmucosaatthesiteoftheinternalopening(a).
ThelinearEndostaplerisfired(b).
ba25Stapledclosureofanalmucosaatthesiteoftheinternalfistulaopening(c).
Inspectionforhaemostasis(d).
dc17PostoperativeCareAllpatientsareadministeredoralDiclofenacsodium75mgBDfor2daysandTabTramadol50mgSOSforbreakthroughpain.
Patientsarealsoadministeredbroadspectrumantibioticsforthreedaysandareusuallydischargedonthesamedayafterrecoveryfromanesthesia.
Thedressingonexternalopeningischangedasrequired.
Patientsarefollowedupat1week,1month,3months,6months,1yearandwheneverrecurrenceofsymptomsnecessitatescare.
DiscussionTraditionalsurgicalproceduresforanalfistulaeincludefistulotomyforsuperficialfistulae,fistulectomyforcomplexanddeepfistulaeandstagedfistulotomywithsetonplacementforhighfistulae.
Theaforementionedproceduresinherentlyleadtoperianalwoundsthatrequireregularchangeofdressingsandlong-termfollowup.
Pain,discomfortandprolongedtimeoffworkarenaturalsequelaeofthesesurgicalprocedures.
Fecalincontinenceisasignificantcomplicationinthesepatients,especiallyincomplexandrecurrentfistulae.
6Thisresultsfromdivisionandinjurytothemusculaturethatconstitutesthesphinctermechanismoftheanalcanal.
TheminimallyinvasiveanalfistulatreatmentwasinitiallydescribedbyMeinero.
6Hestatesthat"Therationaleofthevideo-assistedanalfistulatreatmenttechniqueisbasedonthesameprinciplesasotherproceduresforclosingtheinternalopeningandobliteratingthetract,wheretherealinnovationisconstitutedbyapreciseidentificationofthefistulaanatomyandoftheinternalopeningbyfistuloscopyandfulgurationofthetractwallsunderdirectvision".
6VAAFTqualifiesasatrueminimallyinvasivesurgicalprocedure.
Therearenoiatrogenicincisionsincurredtogainaccesstothesiteofoperativetreatment.
Surgicalaccessisobtainedviathepre-existingpathologicalopeningofthefistula.
TheessentialfeaturesoftheVAAFTtechniqueincludeFistuloscopicexplorationofthefistulatrack.
Identificationoftheinternalfistulaopening.
Identificationofsecondaryfistulatracksandabscesscavities.
Fulgurationanddestructionofthefistulatrackunderdirectvisionandsecurelystapledclosureoftheinternalfistulaopening.
Fistuloscopywithirrigationfacilitatesaccurateidentificationandlocalizationoftheinternalfistulaopeningintheanalcanal.
Indifficultcircumstances,digitalprobingoftheanalcanaltolocatethetipofthefistuloscopeishelpful.
Also,thetransillumi-nationeffectofthefistuloscopiclightshiningthroughthebowelwallmayaidinlocalizingtheinternalfistulaopening.
Basedonourexperience,wecouldnotidentifytheinternalfistulaopeningin24%ofpatients.
Thisisassumedtoarisefromaspontaneousclosureoftheinternalopening.
Inpatients,wherethelightofthefistuloscopecanbeseentransilluminatingthroughaverythinlayerofmucosa,itmaybeadvisabletosecurethemucosalsitebyreinforcementwithanendostapler.
Ifthereisnotransilluminationvisibleonthebowelwallfromthelightofthefistuloscope,oneshouldrefrainfromcreatinganartificialinternalopeningofthefistula.
Inthesepatients,onlyfulgurationanddebridementofthefistulatractmaybeperformed.
Patientsinwhomtheinternalfistulaopeningisnotidentified,arefoundtohaveahigherriskofrecurrence.
The8°-viewingangleofthefistuloscopeisveryusefulinthedetectionofsecondarytracksandabscesscavities,therebyreducingtheriskofrecurrence.
Thefistuloustractisdistructedbyfulgurationunderdirectvision.
DebridementofthefulguratedtractisperformedusingflexiblefistulabrushforacurvedtractandVolkmann'sspoonforastraighttrack.
Asecurelystapledclosureensureshermeticocclusionoftheinternalfistulaopening.
VAAFTinthemanagementofanalfistulaeisanewandevolvingtechnique.
Aswithmanyothernewsurgicaltechniques,usersneedtogothroughalearningcurve.
Inourexperience,whichisbasedonagroupof416patients,in5patientstheinternalopeningoftheanalfistulawasveryhigh(beyondthereachofanoscope).
Thisconditionprecludestheoptionofasecurelystapledclosureoftheinternalopening.
Atpresent,thedefini-tiveendoscopicsurgicalmanagementofsuchpatientsremainsunresolved.
Furthermore,inearlystagesofthesurgeon'slearningcurvewithVAAFT,thereisanelevatedriskthattheinternalfistulaopeningmaynotbeidentified.
Also,secondaryfistulatracksmaybemissed.
Thesefactorscontributetoahigherrecurrencerateinpatientsundergoingtreatmentduringtheinitiallearningphaseofthesurgeon.
However,theresultantmorbidityislimitedastherearenoperianalwoundsandthemusculatureoftheanalsphincterremainsintact.
Thisisofsignificanceastheincidenceoffaecalincontinenceishighwithothersurgicaltreatmentoptionsavailable.
11VAAFTinvolvesaninitialexpenditureforpurchasingtherequiredequipment.
However,thefistuloscopeandancillaryequipmentarereusableandtheinitialcostsarelikelytoberecoveredsoon.
Thetechniqueprovidessignificantadvantagestopatientsintermsofreducedpain,minimalmorbidityandear-lierresumptionofnormalactivities.
Theglobalsocioeconomiccostsofthisprocedurearethereforelikelytobelow.
VAAFTissafeandfeasibleandcanbemostlyperformedasadaycareprocedure.
Therearedistinctadvantagestopatientsintermsofreducedpain,absenceofperianalwounds,fasterrecoveryandearlierreturntowork.
However,applicabilityofVAAFTinveryhighextrasphinctericfistulaeremainsunclearatpresent.
Long-termresultsfrommorecentersareawaited.
18References1.
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19VAAFTInstrumentSetforVideo-AssistedAnalFistulaTreatmentIMAGE1SCameraSystemandAccessories2024511AAFistuloscope8°,angledeyepiece,outerdiameter3.
3*4.
7mm,workinglength18cm,autoclavable,withstraightworkingchannelchannelforinstrumentsuptodiameter2.
5mm,fiberopticlighttransmissionincorporated,colorcode:greenInstrumentSetforVideo-AssistedAnalFistulaTreatment(VAAFT)24513Obturator,forendoscope24515CoagulationElectrode,7Fr.
,forfistulectomy24512Handle24511FistulectomySet,including:Fistuloscope8°,angledeyepiece,outerdiameter3.
3*4.
7mm,workinglength18cm,autoclavable,withstraightinstrumentchannelforinstrumentsuptodiameter2.
5mm,fiberopticlighttransmissionincorporated,colorcode:green,WireTrayforCleaning,SterilizationandStorageObturator100020-10EndoscopicSeal,forsingleuse,forworkingchannelsfor4–10Fr.
instruments,sterile,packageof10Itisrecommendedtocheckthesuitabilityoftheproductfortheintendedprocedurepriortouse.
21InstrumentSetforVideo-AssistedAnalFistulaTreatment(VAAFT)39501XPWireTrayforCleaning,SterilizationandStorage,withintegratedcleaningadaptorforwasher-disinfector,withlid,SparePartsBasket39501XSandsiliconetelescopeholders,externaldimensions(wxdxh):460x150x80mm,forinstrumentswithupto27cmworkinglength24981AUCKLANDEASIAnalDistendingSpeculum,foranalexaminations,with3blades,outerdiameter27mm,workinglength6cm,withObturator24981O,withratchet30251KJCLICKLINEREDDICK-OLSENGraspingForceps,rotating,size2mm,length30cm,withconnectorpinforunipolarcoagulation,doubleactionjaws,withirrigationconnectorforcleaningincluding:PlasticHandle,withoutratchetOuterSheathwithWorkingInsert,insulated24514FistulaBrush,withhandleincluding:3-RingHandleOuterSheath3xFistulaBrushInserts,with4mm,4.
5mmand5mmouterdiameter22InnovativeDesign##Dashboard:Completeoverviewwithintuitivemenuguidance##Livemenu:User-friendlyandcustomizable##Intelligenticons:Graphicrepresentationchangeswhensettingsofconnecteddevicesortheentiresystemareadjusted##Automaticlightsourcecontrol##Side-by-sideview:ParalleldisplayofstandardimageandtheVisualizationmode##Multiplesourcecontrol:IMAGE1Sallowsthesimultaneousdisplay,processinganddocumentationofimageinformationfromtwoconnectedimagesources,e.
g.
,forhybridoperationsDashboardLivemenuSide-by-sideview:ParalleldisplayofstandardimageandVisualizationmodeIntelligenticonsEconomicalandfuture-proof##Modularconceptforflexible,rigidand3Dendoscopyaswellasnewtechnologies##ForwardandbackwardcompatibilitywithvideoendoscopesandFULLHDcameraheads##Sustainableinvestment##CompatiblewithalllightsourcesIMAGE1SCameraSystem23FuLLHDImaging##VeryhighqualityofendoscopicimagesinFULLHD##Naturalcolorrendition##Reflectionisminimized##MultipleIMAGE1Stechnologiesforhomogeneousillumination,contrastenhancementandcolorshiftingFULLHDimageCHROMAFULLHDimageSPECTRAA*FULLHDimageFULLHDimageCLARASPECTRAB***SPECTRAA:NotforsaleintheU.
S.
**SPECTRAB:NotforsaleintheU.
S.
IMAGE1SCameraSystem24TC200EN*IMAGE1SCONNECT,connectmodule,forusewithupto3linkmodules,resolution1920x1080pixels,withintegratedKARLSTORZ-SCBanddigitalImageProcessingModule,powersupply100–120VAC/200–240VAC,50/60Hzincluding:MainsCord,length300cmDVI-DConnectingCable,length300cmSCBConnectingCable,length100cmUSBFlashDrive,32GB,USBsiliconekeyboard,withtouchpad,US*Availableinthefollowinglanguages:DE,ES,FR,IT,PT,RUSpecifications:HDvideooutputsFormatsignaloutputsLINKvideoinputsUSBinterfaceSCBinterface-2xDVI-D-1x3G-SDI1920x1080p,50/60Hz3x4xUSB,(2xfront,2xrear)2x6-pinmini-DIN100–120VAC/200–240VAC50/60HzI,CF-Defib305x54x320mm2.
1kgPowersupplyPowerfrequencyProtectionclassDimensionswxhxdWeightTC300IMAGE1SH3-LINK,linkmodule,forusewithIMAGE1FULLHDthree-chipcameraheads,powersupply100–120VAC/200–240VAC,50/60Hz,forusewithIMAGE1SCONNECTTC200ENincluding:MainsCord,length300cmLinkCable,length20cmForusewithIMAGE1SIMAGE1SCONNECTModuleTC200ENIMAGE1SCameraSystemTC300(H3-Link)TH100,TH101,TH102,TH103,TH104,TH106(fullycompatiblewithIMAGE1S)22220055-3,22220056-3,22220053-3,22220060-3,22220061-3,22220054-3,22220085-3(compatiblewithoutIMAGE1StechnologiesCLARA,CHROMA,SPECTRA*)1x100–120VAC/200–240VAC50/60HzI,CF-Defib305x54x320mm1.
86kgCameraSystemSupportedcameraheads/videoendoscopesLINKvideooutputsPowersupplyPowerfrequencyProtectionclassDimensions(wxhxd)WeightSpecifications:TC200ENTC300*SPECTRAA:NotforsaleintheU.
S.
**SPECTRAB:NotforsaleintheU.
S.
25TH104TH104IMAGE1SH3-ZAThree-ChipFULLHDCameraHead,50/60Hz,IMAGE1Scompatible,autoclavable,progressivescan,soakable,gas-andplasma-sterilizable,withintegratedParfocalZoomLens,focallengthf=15–31mm(2x),2freelyprogrammablecameraheadbuttons,forusewithIMAGE1SandIMAGE1HUBHD/HDIMAGE1FULLHDCameraHeadsProductno.
ImagesensorDimensionswxhxdWeightOpticalinterfaceMin.
sensitivityGripmechanismCableCablelengthIMAGE1SH3-ZATH1043x1/3"CCDchip39x49x100mm299gintegratedParfocalZoomLens,f=15–31mm(2x)F1.
4/1.
17Luxstandardeyepieceadaptornon-detachable300cmSpecifications:TH100IMAGE1SH3-ZThree-ChipFULLHDCameraHead,50/60Hz,IMAGE1Scompatible,progressivescan,soakable,gas-andplasma-sterilizable,withintegratedParfocalZoomLens,focallengthf=15–31mm(2x),2freelyprogrammablecameraheadbuttons,forusewithIMAGE1SandIMAGE1HUBHD/HDIMAGE1FULLHDCameraHeadsProductno.
ImagesensorDimensionswxhxdWeightOpticalinterfaceMin.
sensitivityGripmechanismCableCablelengthIMAGE1SH3-ZTH1003x1/3"CCDchip39x49x114mm270gintegratedParfocalZoomLens,f=15–31mm(2x)F1.
4/1.
17Luxstandardeyepieceadaptornon-detachable300cmSpecifications:ForusewithIMAGE1SCameraSystemIMAGE1SCONNECTModuleTC200EN,IMAGE1SH3-LINKModuleTC300andwithallIMAGE1HUBHDCameraControlUnitsIMAGE1SCameraHeadsTH100269826NB26"FULLHDMonitor,wall-mountedwithVESA100adaption,colorsystemsPAL/NTSC,max.
screenresolution1920x1080,imagefomat16:9,powersupply100–240VAC,50/60Hzincluding:External24VDCPowerSupplyMainsCord9619NB19"HDMonitor,colorsystemsPAL/NTSC,max.
screenresolution1280x1024,imageformat4:3,powersupply100–240VAC,50/60Hz,wall-mountedwithVESA100adaption,including:External24VDCPowerSupplyMainsCordMonitors27MonitorsOptionalaccessories:9826SFPedestal,formonitor9826NB9626SFPedestal,formonitor9619NB26"9826NBl–lllll–l–llllll19"9619NBl––lllllll–lllllKARLSTORZHDandFULLHDMonitorsWall-mountedwithVESA100adaptionInputs:DVI-DFibreOptic3G-SDIRGBS(VGA)S-VideoComposite/FBASOutputs:DVI-DS-VideoComposite/FBASRGBS(VGA)3G-SDISignalFormatDisplay:4:35:416:9Picture-in-PicturePAL/NTSCcompatible19"optional9619NB200cd/m2(typ)178°vertical0.
29mm5ms700:1100mmVESA7.
6kg28W0–40°C-20–60°Cmax.
85%469.
5x416x75.
5mm100–240VACEN60601-1,protectionclassIPX0Specifications:KARLSTORZHDandFULLHDMonitorsDesktopwithpedestalProductno.
BrightnessMax.
viewinganglePixeldistanceReactiontimeContrastratioMountWeightRatedpowerOperatingconditionsStorageRel.
humidityDimensionswxhxdPowersupplyCertifiedto26"optional9826NB500cd/m2(typ)178°vertical0.
3mm8ms1400:1100mmVESA7.
7kg72W5–35°C-20–60°Cmax.
85%643x396x87mm100–240VACEN60601-1,UL60601-1,MDD93/42/EEC,protectionclassIPX22820535201-125AUTOCONII400HighEnd,SetSCBpowersupply220-240VAC,50/60Hz,HFconnectingsockets:Bipolarcombination,Multifunction,Unipolar3-pin+ErbeNeutralelectrodecombination6.
3mm,jackand2-pin,Systemrequirements:SCBR-UISoftwareRelease20090001-43orhigherincluding:AUTOCONII400,withKARLSTORZSCBMainsCordSCBConnectingCable,length100cmNecessaryAccessories:20017831Three-PedalFootswitch,forusewithHFgeneratorsAUTOCONII400andAUTOCONII200AUTOCONII400SCBColdLightFountainPowerLED175SCB20161401-1ColdLightFountainPowerLED175SCB,withintegratedSCB,high-performanceLEDandoneKARLSTORZlightoutlet,powersupply110–240VAC,50/60Hzincluding:ColdLightFountainPowerLEDMainsCordSCBConnectingCable,length100cm20132026Xenon-Spare-Lamp,175Watt,15Volt495NLFiberOpticLightCable,diameter3.
5mm,length180cm495NAFiberOpticLightCable,diameter3.
5mm,length230cm29EquipmentCartUG540MonitorSwifelArm,heightandsideadjustable,canbeturnedtotheleftortherightside,swivelrange180°,overhang780mm,overhangfromcentre1170mm,loadcapacitymax.
15kg,withmonitorfixationVESA5/100,forusagewithequipmentcartsUGxxxUG540UG220UG220EquipmentCartwide,high,rideson4antistaticdualwheelsequippedwithlockingbrakes3shelves,mainsswitchontopcover,centralbeamwithintegratedelectricalsubdistributorswith12sockets,holderforpowersupplies,potentialearthconnectorsandcablewindingontheoutside,Dimensions:Equipmentcart:830x1474x730mm(wxhxd),shelf:630x510mm(wxd),casterdiameter:150mminluding:Basemoduleequipmentcart,wideCoverequipment,equipmentcartwideBeampackageequipment,equipmentcarthigh3xShelf,wideDrawerunitwithlock,wide2xEquipmentrail,longCameraholder30RecommendedAccessoriesforEquipmentCartUG310IsolationTransformer,200V–240V;2000VAwith3specialmainssocket,expulsionfuses,3groundingplugs,dimensions:330x90x495mm(wxhxd),forusagewithequipmentcartsUGxxxUG310UG410EarthLeakageMonitor,200V–240V,formountingatequipmentcart,controlpaneldimensions:44x80x29mm(wxhxd),forusagewithisolationtransformerUG310UG410UG510MonitorHoldingArm,heightadjustable,inclinable,mountableonleftorright,turningradiusapprox.
320°,overhang530mm,loadcapacitymax.
15kg,monitorfixationVESA75/100,forusagewithequipmentcartsUGxxxUG51031Notes:32Notes:33Notes:34Notes:withthecomplimentsofKARLSTORZ—ENDOSKOPE