Long-term outcomes with the use of bioprosthetic plugs for the management of complex anal fistulas

Gore Bio-A® Fistula Plug: a new sphincter-sparing procedure for complex anal fistula

AIM

The surgical treatment of a complex anal fistula remains controversial, although 'sphincter-saving' operations are desirable. The Gore Bio-A® Fistula Plug is a new bioprosthetic plug that has been proposed for the treatment of complex anal fistula. This study reports preliminary data following implantation of this plug.

METHOD

Eleven patients with a complex anal fistula underwent insertion of Gore Bio-A® Fistula Plugs. The disc diameter and number of tubes in the plug were adapted to the fistula to allow accommodation of the disc into a submucosal pocket, and the excess tubes were trimmed. During the follow-up period, patients underwent clinical and physical examinations and three-dimensional endoanal ultrasound.

RESULTS

Fistulas were high anterior transphincteric in five patients and high posterior transphincteric in six patients. All patients had a loose seton placement before plug insertion. Two, three and four tubes were inserted into the fistula plug in seven, three and one patient, respectively. The median follow-up period was 5 months. No patient reported any faecal incontinence. There was no case of early plug dislodgement. Treatment success was noted for eight (72.7%) of 11 patients at the last follow-up appointment.

CONCLUSION

Implanting a Gore Bio-A® Fistula Plug is a simple, minimally invasive, safe and potentially effective procedure to treat complex anal fistula. Patient selection is fundamental for success.

A systematic review of the anal fistula plug for patients with Crohn's and non-Crohn's related fistula-in-ano

BACKGROUND

The management of fistula-in-ano is a balance between fistula cure and preservation of continence.

OBJECTIVE

The aim of this study is to summarize the anal fistula plug literature for Crohn's and non-Crohn's fistula-in-ano in a homogenous patient population.

DATA SOURCES

PubMed, MEDLINE, Embase, and Cochrane medical databases were searched from 1995 to 2011. Abstracts from The American Society of Colon and Rectal Surgeons, The Society for Surgery of the Alimentary Tract, The European Society of Coloproctology, and the Association of Coloproctology of Great Britain and Ireland meetings between 2007 and 2010 were also evaluated.

STUDY SELECTION

Studies were included if results for patients with and without Crohn's disease could be differentiated. Patients with rectovaginal, anovaginal, rectourethral, or ileal-pouch vaginal fistulas were excluded as were studies where the mean or median follow-up was less than 3 months. Two researchers independently selected studies matching the inclusion criteria.

INTERVENTION

Anal fistula plug insertion was performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were the overall fistula closure rates and length of follow-up.

RESULTS

Seventy-six articles or abstracts were identified from the title as being of relevance. Twenty studies (2 abstracts, 18 articles) were finally included. Study sample size ranged from 4 to 60 patients; 530 patients were included in all studies (488 non-Crohn's and 42 Crohn's patients). The plug extrusion rate was 8.7% (46 patients). The proportion of patients achieving fistula closure varied widely between studies for non-Crohn's, ranging from 0.2 (95% CI 0.04-0.48) to 0.86 (95% CI 0.64-0.97). The pooled proportion of patients achieving fistula closure in patients with non-Crohn's fistula-in-ano was 0.54 (95% CI 0.50-0.59). The proportion achieving closure in patients with Crohn's disease was similar (0.55, 95% CI 0.39-0.70).

LIMITATIONS

This study was limited by the variability of operative technique and perioperative care between studies.

CONCLUSIONS

Fistula closure is achieved by using the anal fistula plug in approximately 54% of patients without Crohn's disease. The anal fistula plug has not been adequately evaluated in the Crohn's population.

New techniques for treating an anal fistula

Surgery for an anal fistula may result in recurrence or impairment of continence. The ideal treatment for an anal fistula should be associated with low recurrence rates, minimal incontinence and good quality of life. Because of the risk of a change in continence with conventional techniques, sphincter-preserving techniques for the management complex anal fistulae have been evaluated. First, the anal fistula plug is made of lyophilized porcine intestinal submucosa. The anal fistula plug is expected to provide a collagen scaffold to promote tissue in growth and fistula healing. Another addition to the sphincter-preserving options is the ligation of intersphincteric fistula tract procedure. This technique is based on the concept of secure closure of the internal opening and concomitant removal of infected cryptoglandular tissue in the intersphincteric plane. Recently, cell therapy for an anal fistula has been described. Adipose-derived stem cells have two biologic properties, namely, ability to suppress inflammation and differentiation potential. These properties are useful for the regeneration or the repair of damaged tissues. This article discusses the rationales for, the estimated efficacies of, and the limitations of new sphincter-preserving techniques for the treatment of anal fistulae.

Long-term outcomes of human acellular dermal matrix plug in closure of complex anal fistulas with a single tract

BACKGROUND

Bioprosthetic plugs represent a promising technique for the treatment of anal fistula simple because they allow simple and repeatable application, preservation of sphincter integrity, minimal patient discomfort, and subsequent surgical options if needed. However, success rates vary widely.

OBJECTIVE

The aim of this study was to assess long-term outcome in patients treated with an acellular dermal matrix plug for closure of complex single-tract anal fistulas.

DESIGN

This was a retrospective analysis of a prospective database.

SETTING

The study was conducted at a university hospital in Beijing, People's Republic of China.

PATIENTS

The study population comprised 114 patients treated between January 2007 and May 2010 for complex high transsphincteric anal fistula with a single tract.

INTERVENTION

Fistulas were treated with an acellular dermal matrix plug derived from donated human skin.

MAIN OUTCOME MEASURES

The main outcome measures were fistula closure rate and postoperative incontinence (Wexner scores).

RESULTS

No mortality or major complications were observed. The overall success rate was 54.4% (62/114), with a median follow-up of 19.5 (range, 11-46) months. Of the 52 patients with plug failure, 11 (21%) had plug extrusion and 9 (17%) had sepsis. Most plug failures occurred within 30 days, with only 1 plug failure occurring 6 months after surgery. On multiple logistic regression analysis, smoking (P < .001), long distance between external opening (P < .001), and performance of the operation by a nonexpert surgeon (P = .018) were significantly associated with plug failure. Of 40 patients who underwent cutting seton placement after plug failure, 33 (82.5%) reported a successful outcome. However, the rate of incontinence 6 months after seton placement was 75% (30/40), whereas the rate in the overall study population 6 months after insertion of the ADM plug was 1.75% (2/114; P < .001).

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSIONS

Given the low morbidity and relative simplicity of the procedure, we suggest that an acellular dermal matrix plug is a reasonable option for closure of complex anal fistulas with a single tract.

Cryptoglandular anal fistulas

BACKGROUND

Cryptoglandular anal fistula arises in 2 per 10 000 persons per year and is most common in young men. Improper treatment can result in fecal incontinence and thus in impaired quality of life.

METHOD

This S3 guideline is based on a systematic review of the pertinent literature.

RESULTS

The level of evidence for treatment is low, because relevant randomized trials are scarce. Anal fistulae are classified according to the relation of the fistula channel to the sphincter. The indication for treatment is established by the clinical history and physical examination. During surgery, the fistula should be probed and/or dyed. Endo-anal ultrasonography and magnetic resonance imaging are of roughly the same diagnostic value and may be useful as additional studies for complex fistulae. Surgical treatment is with one of the following operations: laying open, seton drainage, plastic surgical reconstruction with suturing of the sphincter, and occlusion with biomaterials. Only superficial fistulae should be laid open. The risk of postoperative incontinence is directly related to the thickness of sphincter muscle that is divided. All high anal fistulae should be treated with a sphincter-saving procedure. The various plastic surgical reconstructive procedures all yield roughly the same results. Occlusion with biomaterials yields a lower cure rate.

CONCLUSION

This is the first German S3 guideline for the treatment of cryptoglandular anal fistula. It includes recommendations for the diagnostic evaluation and treatment of this clinical entity.

A new technique for sphincter-preserving anal fistula repair using a novel radial emitting laser probe

Anal fistula repair still remains challenging. Up to 30% of fistulas persist after surgery despite many improvements in surgical skills and technique. One major reason for surgical failure is a persistent fistula track or remnants of the fistula epithelium which could not be removed during surgery. To overcome this problem, a novel technique was developed using a newly invented radial emitting laser probe ("FiLaC™", Biolitec, Germany) to destroy the fistula epithelium and to simultaneously obliterate the remaining fistula track. In a pilot study, we operated on 11 patients with cryptoglandular anal fistula. All patients underwent previous surgery up to 6 times prior to definitive surgery. In the primary operation, the initial abscess was drained, the internal opening of the fistula identified and seton drainage placed. During fistula repair, we used the flap technique for conventional closure of the internal opening. The remaining fistula track was cleaned mechanically, the laser inserted into the track and energy applied homogeneously at a wavelength of 1,470 nm and 13 watt. While providing continuous retraction of the probe, the remaining epithelium was destroyed and the fistula track obliterated. The median follow-up was 7.4 months. Nine out of 11 fistulas showed primary healing (81.8%). Only one minor form of incontinence (limited soiling) was observed and no complications occurred. The use of a novel diode laser source and a radial emitting laser probe in addition to conventional surgery is a very promising new technique in sphincter-preserving anal fistula repair. The observed healing rate is high. Due to minimized trauma to the sphincter muscle, there are good short-term functional results without observable procedure-related complications.

Idiopathic fistula-in-ano

Fistula-in-ano is the most common form of perineal sepsis. Typically, a fistula includes an internal opening, a track, and an external opening. The external opening might acutely appear following infection and/or an abscess, or more insiduously in a chronic manner. Management includes control of infection, assessment of the fistulous track in relation to the anal sphincter muscle, and finally, definitive treatment of the fistula. Fistulotomy was the most commonly used mode of management, but concerns about post-fistulotomy incontinence prompted the use of sphincter preserving techniques such as advancement flaps, fibrin glue, collagen fistula plug, ligation of the intersphincteric fistula track, and stem cells. Many descriptive and comparative studies have evaluated these different techniques with variable outcomes. The lack of consistent results, level I evidence, or long-term follow-up, as well as the heterogeneity of fistula pathology has prevented a definitive treatment algorithm. This article will review the most commonly available modalities and techniques for managing idiopathic fistula-in-ano.

The anal fistula plug treatment compared with the mucosal advancement flap for cryptoglandular high transsphincteric perianal fistula: a double-blinded multicenter randomized trial

BACKGROUND

The anal fistula plug was developed as an alternative treatment for perianal fistulas.

OBJECTIVE

This study aimed to compare the anal fistula plug with the mucosal advancement flap for the treatment of high transsphincteric fistulas.

DESIGN

This study was a double-blinded, multicenter, randomized trial.

PATIENTS

Sixty patients with perianal fistulas were randomly assigned to receive an anal fistula plug or a mucosal advancement flap and were blinded for the type of treatment.

MAIN OUTCOME MEASURES

The outcome measures comprised the closure rate, postoperative pain, continence (colorectal functional outcome, Vaizey, and Wexner scores), and quality of life. Closure was determined by clinical examination by a surgeon blinded for the intervention.

RESULTS

At a follow-up of 11 months the recurrence rates were 71% (n = 22) in the anal fistula plug group and 52% (n = 15) in the mucosal advancement flap group, which was not significantly different. There were no significant differences in postoperative pain, in pre- and postoperative incontinence scores, soiling, and quality of life.

CONCLUSIONS

The results of the anal fistula plug and advancement flap procedures are disappointing in the multicenter setting. There were no significant differences in recurrence, functional outcome, and quality of life between the plug and the advancement flap. Because the plug is simple to apply and minimally invasive, it can be considered as an initial treatment option for high transsphincteric fistulas.

New developments in colorectal surgery

PURPOSE OF REVIEW

New developments in colorectal surgery have been driven primarily by technical innovations, which in turn are responsible for changes in practice. This review examines recent publications that describe and have contributed to these changes.

RECENT FINDINGS

We identified and reviewed recent publications in the areas of fecal incontinence, constipation, single incision and robotic surgical techniques, complex anal fistulas, diverticulitis, local excision techniques for rectal neoplasms, surgical care improvement, use of mechanical bowel preparation, and magnetic resonance imaging after neoadjuvant chemoradiotherapy for rectal cancer.

SUMMARY

New technologies and practice innovations will enhance patient outcomes and quality of life. Multiinstitutional studies, randomized when practical, will be necessary to further define the safety and efficacy of these new surgical techniques and to further define best practices in colon and rectal surgery.

Sphincter-preserving fistula management: what patients want

PURPOSE

The purpose of this study was to determine how patients with anal fistulas would rank clinical scenarios describing various management options for anal fistulas.

METHOD

A survey was administered to 74 consecutive patients with anal fistulas. On each survey, 10 clinical scenarios describing various treatment options for anal fistulas were scored from 1 (most likely to select) to 10 (least likely to select). Mean scores for each scenario were calculated and compared by use of a Student t test.

RESULTS

When combined, 74% of patients selected a sphincter-preserving technique as their primary choice compared with 26% who chose a fistulotomy (P < .0001). Compared with the highest ranking sphincter-preserving techniques, the mean scores of the scenarios involving a fistulotomy were significantly (P < .05) lower (less likely to select). The mean score of a traditional fistulotomy was the same as the mean score of a sphincter-preserving technique with a 50% success rate but no risk of diminished continence.

CONCLUSIONS

These data suggest that the majority of patients with an anal fistula will select a sphincter-preserving technique to manage their fistula. This finding may indicate that, within limits, it is of greater importance for most patients to minimize their risk of diminished continence than to have a highly successful treatment strategy for their fistula.

Outcomes with the use of bioprosthetic grafts to reinforce the ligation of the intersphincteric fistula tract (BioLIFT procedure) for the management of complex anal fistulas

PURPOSE

This study was undertaken to determine the outcomes of patients whose complex anal fistulas were managed by ligation of the intersphincteric fistula tract reinforced with a bioprosthetic graft (BioLIFT procedure).

METHODS

A retrospective analysis was performed of all patients whose anal fistula was managed by use of the BioLIFT technique between May 2005 and May 2008, who had a minimum of 1 year of follow-up after their last treatment.

RESULTS

The BioLIFT technique using a bioprosthetic graft was used to treat a complex anal fistula in 31 patients (22 men, 9 women; mean age, 48 y (range, 30-68 y). Clinical healing of the fistula, defined as the absence of drainage with no evidence of residual fistula tract, occurred in 29 (94%) patients. No complications occurred that required intervention.

CONCLUSIONS

The BioLIFT procedure is effective for the management of complex fistulas-in-ano. Randomized clinical trials comparing this technique with other sphincter-preserving methods for fistula management need to be performed to further determine the role of this technique in the management of anal fistulas.