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sábado, 29 de septiembre de 2012

Videoscopia aplicada al tratamiento de la fístula anal.VAAFT ( Video-assisted anal fistula treatment )


Las técnicas quirúrgicas actuales para el tratamiento de las fístulas anales se basan en tres principios fundamentales: la identificación del trayecto y el orificio interno, la escisión del trayecto fistuloso y la preservación de la función del esfínteriana. Fistulotomía / fistulectomía son los “gold standard” para el tratamiento de las fístulas anales , sin embargo estas técnicas aplicadas a las fístulas complejas no obtienen los  mejores resultados , ya que la tasas de recidiva así como de incontinencia por lesión esfinteriana son altas . El fundamento de la técnica VAAFT (Video-assisted anal fistula treatment ) se basa en el concepto de la identificación del trayecto  bajo visión directa  y el cierre  del orificio interno de la fístula, así como la destrucción del trayecto y su limpieza, lo que en teoría promovería la cicatrización completa y definitiva.
El articulo de Meinero publicado en Techniques in Coloproctology en 2011, analiza los resultados obtenidos con el VAAFT en una serie de 136 pacientes, aunque solo se siguieron 62 durante un año, en este grupo el 87,1% estaban curados.
La principal ventaja  de la técnica VAAFT es que el procedimiento se realiza enteramente bajo visión directa endoluminal. Con este enfoque, el orificio interno se encuentra en 82,6% de los casos. Por otra parte, la fistuloscopia ayuda a identificar las posibles trayectos secundarios o abscesos crónicos. La técnica VAAFT  preserva la función esfínteriana, y las heridas quirúrgicas son extremadamente pequeñas.
Existe una gran variación en cuanto a la  dificultad técnica y eficacia  de otras técnicas aplicadas a las fistulas anales complejas de origen criptoglandular .
 Los colgajos de avance son técnicamente difíciles y están asociados con tasas de recurrencia que varían de 2 al 54% . Por otro lado , los colgajos de avance se asocian a menudo con incontinencia postoperatoria, y la incidencia de esta complicación según algunas series se  aproxima al 35% .
La inyección de fibrina en el trayecto fistuloso  es  técnicamente fácil y posee la ventaja de su reversibilidad, pero los resultados han sido decepcionantes,  a largo plazo obtiene tasas de éxito tan bajas como el 16% . Del mismo modo, el uso de tapones para ocluir el trayecto preservando la función  esfínteriana , además de un método caro, obtiene unas tasas de éxito que oscilan entre el 29% y el 87% .
Recientemente Wilhelm A. publicó en Tech Coloproctol. otra técnica novedosa para el tratamiento de fístulas complejas, el FiLaC ™ .
 En este artículo los autores combinan  un cierre convencional del orificio interno , utilizando un colgajo , con  la obliteración  del trayecto usando una fibra láser radial. En un grupo de 17 pacientes con una mediana de seguimiento de 9 meses, publican una tasa de curación del 82,3%. Este enfoque, al igual que VAAFT, tiene como objetivo la destrucción de las vías y la preservación de los esfínteres, pero es un procedimiento que se realiza a ciegas, sin ventajas para identificar el orificio interno, vías secundarias y cavidades o abscesos.
Los resultados del VAAFT parecen prometedores, lo que confirma los resultados de Ortiz et al.  Publicados en 2008 en Br J Surg , en este articulo se publican los resultados de una técnica que sigue los mismos principios que el VAAFT , aunque sin el uso de la fistuloscopia.

Veamos un video de la técnica VAAFT.

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