Flap and FiLaC™ duo heals a complex grade IV anal fistula: case report of a surgical success

Abstract

Complex anal fistulas, particularly those classified as grade IV, present significant management challenges due to their intricate anatomy, risk of recurrence, and potential for sphincter damage leading to incontinence. Traditional sphincter-sparing techniques such as anal mucosal advancement flap has been widely used, while minimally invasive approaches like fistula laser closure (FiLaC™) have emerged as adjunctive therapies. This case report describes a successful treatment of a 44-year-old male with a complex trans-sphincteric fistula using a combination of mucosal advancement flap and FiLaC™ laser ablation. A 44-year-old male presented with chronic purulent discharge from multiple perianal swellings for three years. Magnetic resonance imaging (MRI) fistulogram identified a grade IV complex trans-sphincteric fistula (St. James's University Hospital Classification) with a single internal opening at 6 o'clock and multiple ramifications. Under regional anesthesia, the patient underwent surgical exploration. Three external tracts located at 1, 3, and 5 o'clock positions were traced to a single trans-sphincteric internal opening. The internal opening was closed with 2-0 vicryl sutures. Laser ablation using FiLaC™ was performed after thorough curettage, followed by creation and advancement of a healthy anal mucosal flap to cover the internal opening.