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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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