Specialist in Emergency Surgery
Colorectal Surgery

FAQ

How does VAAFT differ from traditional methods of treating anal fistulas?
The main characteristic of VAAFT procedure is the direct vision. Thanks to the Fistuloscope, we can see inside the fistula, and recognize any possible secondary tracts or abscess cavities. Moreover, VAAFT is a minimally-invasive and sphincter-saving procedure.

What are the main indications for VAAFT in the treatment of anal fistulas?
All complex anal fistula and their recurrences, even in case of Crohn’s disease.

Can VAAFT be used for complex or recurrent anal fistulas?
VAAFT is mainly indicated for complex and recurrent anal fistulas. It is not indicated for simple fistulas.

What are the potential complications or risks associated with VAAFT?
If the Fistuloscope is not properly used, like for instance if it would be a metallic probe, there might be the risk to broke the fistula, so compromising all the surgical treatment. This is the reason that it is necessary an appropriate period in training.

Is VAAFT suitable for patients with Crohn's disease who develop anal fistulas?
Sure. Two years ago, in five different Institutions, we started a very interesting study on this subject. We treat all fistulas and abscesses in patients suffering from Crohn’s disease with VAAFT and, after two weeks, we start the biologic therapy, without using any setons, because all the infected areas are completely treated. By doing so, we give the patient a better quality of life and accelerate the healing time.

Can VAAFT be used as a first-line treatment for anal fistulas, or is it typically reserved for specific cases?
Yes. When it is feasible, in all cases of complex anal fistula, VAAFT should be the first-line treatment, because the fistula internal wall is “virgin”, and we can correctly identify the main tract and any possible secondary pathways or/and abscess cavities. In case of recurrence, even more so, VAAFT is really indicated, even if, unfortunately, we are now doing surgery on patients who underwent surgery several times, and the surgical site is rich in scars and tough tissue.

I have just started doing VAAFT in Birmingham, England. What are your results with VAAFT in IBD anal fistula?
They are very promising. It depends not so much on the technique, but above all on how we close the internal opening in the anal canal in which the tissues could be compromised because of the underlying disease. However, thanks to the early commencement of the biologic therapy, after VAAFT surgery, our success rate stands at around 69%-72%, which is, in our opinion, a very acceptable result.

How is the fistula tract sealed or closed during VAAFT, and what materials are used for this purpose?
The aim of VAAFT procedure, is not the fistula sealing, but the fistula “burning” from the inside. By doing so, we end to activate the fibrosis process, so getting a gradual and progressive fistula healing. In the past, we applied half-a-millilitre of cyanoacrylate, immediately behind the suture into the anal canal in order to reinforce it, but we didn’t see any significant improvement in terms of internal opening closure. Actually, we had three severe case of big abscesses which required a surgical treatment in Emergency. We also tried the use of the Permacol Paste, but with poor results.

What is the recurrence percentage?
From 25 to 30%. In our opinion these results are very good, if we consider that we are talking about complex anal fistulas and their recurrences. We have to be honest towards the patient, but also ourselves.

Are there ongoing research and advancements in VAAFT techniques and outcomes?
Yes, there are many ongoing research and studies, both from the technological and surgical point of view. We are now focused on the possibility to combine different techniques, after correctly selecting the patient. For example, we combine VAAFT and LIFT if the patient underwent surgery several times. This is because the internal opening closure, into the anal canal, can be very difficult because of the scar tissue around the internal opening. So, the closure of the fistula into the inter-sphincteric space could be a good solution.

Is VAAFT suitable for patients with high trans-sphincteric or supra-sphincteric anal fistulas?
Yes. VAAFT is particularly indicated in those cases, in which the traditional techniques would require large wounds and, above all, could cause some sphincter damages with a consequent high risk of postoperative faecal incontinence.

How many VAAFT procedures have you performed, and what is your level of experience with this technique?
From 2006 to date, I performed about 2500 VAAFT procedures. So, I wouldn’t mean to sound presumptuous, my level of experience is very high on this subject.

Where can I get your VAAFT publications?
You can find them on Pub-Med.

What are your thoughts for using a stapler to close the internal opening?
The use the stapler, both circular and linear, is recommended when the patient is never underwent surgery. In fact, especially in a female, the mucosa of the anal canal is complacent, and lets you lift it by pulling the two stitches, previously placed on the internal opening during the VAAFT diagnostic phase. This manoeuvre lets have a sort of “volcano” at the base of which we can put the stapler and complete the mechanical suture. To date, we use the stapler in about 10-15% of cases.

How will VAAFT contribute to the overall advancement of minimally invasive surgical techniques in the future?
Paradoxically, I think we still are at the beginning. First of all, we have to change our mindset and consider this big head-scratch from another point of view. Albert Einstein said:” We cannot solve a problem with the same mindset that created it”. The technological improvements and the improved knowledge of the etiopathology and the biologic behaviour of the anal fistulas will be decisive. Another highlight will be the combination between two or more minimally-invasive techniques. So VAAFT is a very good technique, and is a very useful opportunity for a colorectal surgeon.

Can you outline the most significant technological advancements that have influenced the progression of VAAFT procedures?
More than talking about the most significant technological advancements, I would say that the most important things that influenced the positive progression and the spreading of VAAFT (and more generally of other minimally-invasive surgical procedures) is the poor success that the traditional techniques have got, maybe not in terms of healing rate, but certainly in terms of patient’s quality of life, postoperative management, return to work, pain intensity and patient’s discomfort in the relationship with others.

Are there specific types of anal fistulas that have seen more substantial improvements in treatment through VAAFT?
Absolutely. A supra-sphincteric or extra-sphincteric fistula with secondary tracts and abscess cavities in a very high site, like in the ischio-rectal fossa or more deep spaces, the VAAFT procedure has given best results if compared with traditional techniques. It is clear that if we use a lay-open procedure with immediate sphincter repair, we can have very good results, but with a high probability to cause sphincter damages, which end to determine various level of postoperative faecal incontinence (30% to the gas, 8% to the liquid stools and 2% to the hard stools).

What have been the main challenges encountered in the progression of VAAFT, and how have they been addressed?
I think that the main challenges I had to face were the difficult of many Colleagues to change their mindset, rejecting “a priori” this new proposal. But the most important challenges overcome with passion and teamwork. It takes time, a long time. But when you see desperate patients healing after long periods of suffering, who underwent surgery several times, I assure you this give you the strength to face any difficulties.

Are there efforts to make VAAFT more widely available in healthcare systems around the world?
Absolutely yes. VAAFT is now available in many public hospitals all over the world. However, I think that it still takes two or three years more to have the largest diffusion, by the fact that everybody confirm the positive outcomes, now so evident in the literature.

How might the future of VAAFT contribute to reducing the recurrence rates of anal fistulas?
I think that the direct vision is always useful for any surgical techniques. Already now, thanks to the direct vision we have got a significant improvement of the healing rate, at least 10% more. It could seem a poor result, but if we consider the type of fistula we are treating, we should be pleased with these outcomes. We are convinced that the combination of various techniques will be the future, along with the new therapeutic acquisitions (stem cells? Immunomodulators?).

My colleague has had some positive results with VAAFT and platelet derived fibroblast factor in the ablated fistula tract. Your thoughts about using adjuncts like this including laser?
Personally, we didn’t have any improvement of our result using the laser, but only a rising costs. As I answered above, the combination of various techniques will be the future for the anal fistula treatment

What measures do you take to ensure patient safety during the VAAFT?
No particular measures are required. Spinal anaesthesia with a mild sedation is done. The patient is placed in the lithotomic position. Two grams of Cefazoline is done as a prophylaxis, half-an-hour before starting VAAFT. The postoperative pain is treated with a few painkillers (Paracetamol, Ketorolac, Diclofenac), which are progressively tapered and then suspended after a few days. Very important are the postoperative recommendations. At the time of the patients’ discharging, we give them a brochure about all thinks they have to do at home. We ask them to keep open the external opening(s) with a syringe with some saline solution, to do hot baths at least twice a day, to take a painkiller if necessary, and to change the dressing once or twice a day. A close follow-up is organised, and the patient is asked to keep in touch with us.

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