Long-term results change conclusions on BioGlue in the treatment of high transsphincteric anal fistulas

Analysis and description of disease-specific quality of life in patients with anal fistula

INTRODUCTION

In patients diagnosed with anal fistula, knowing the quality of life specifically related to the disease can help coloproctology specialists to choose the most appropriate therapeutic strategy for each case. The aim of our study is to analyzse and describe the factors related to the specific quality of life in a consecutive series of patients diagnosed with anal fistula.

METHODS

Observational, cross-sectional study carried out from March 2015 to February 2017. All patients were assessed in the colorectal surgery unit of a hospital in southeast of Spain. After performing an initial anamnesis and a physical examination, patients diagnosed with anal fistula completed the Quality of Life in Ppatients with Anal Fistula Questionnaire (QoLAF-Q). This questionnaire specifically measures quality of life in people with anal fistula and its score range is the following: zero impact = 14 points, limited impact = 15 to 28 points, moderate impact = 29 to 42 points, high impact = 43 to 56 points, and very high impact = 57 to 70 points.

RESULTS

A total of 80 patients were included. The median score obtained in the questionnaire for the sample studied was 34.00 (range=14-68). Statistically significant differences between patients with "primary anal fistula" (n=65) and "recurrent anal fistula" (n=15) were observed (mean rank=42.96 vs. mean rank=29.83, p=0.048). Furthermore, an inverse proportion (P=.016) between "time with clinical symptoms" and "impact on quality of life" was found (<6 months: mean rank = 45.55; 6-12 months: mean rank = 44.39; 1-2 years: mean rank = 37.83; 2-5 years: mean rank = 22; >5 years: mean rank = 19.00). There were no statistically significant differences (P=.149) between quality of life amongst patients diagnosed with complex (mean rank = 36.13) and simple fistulae (mean rank = 43.59).

CONCLUSIONS

Anal fistulae exert moderate-high impact on patients' quality of life. "Shorter time experiencing clinical symptoms" and the "presence of primary fistula" are factors that can be associated with worse quality of life.

Novel biological strategies in the management of anal fistula

BACKGROUND

The mostly widely studied biomaterials for the sphincter sparing treatment of anal fistulas are fibrin glue and the anal fistula plug (AFP). However their overall mean clinical success is only 50-60%. As the understanding of the pathology of anal fistula, wound healing and the host response to materials has improved, so new biological sphincter-sparing strategies have been developed. The aim of this review is to assess the safety and efficacy of these novel techniques.

METHOD

PubMed, the Cochrane database and EMBASE were independently searched. All studies that investigated the potential of a biomaterial (defined as any synthetic or biologically derived substance in contact with host tissue) to augment the healing of anal fistula without sphincter division were included. Studies solely describing the role of fibrin glue or an AFP were excluded. Data extraction included type of material, fistula aetiology, treatment of the primary tract, fistula healing, incontinence, duration of follow-up and any specific complications. Systematic quality assessment of the included articles was performed.

RESULTS

Twenty-three articles were finally selected for review. These included a variety of biological and synthetic systems that were employed to deliver selected components of the extracellular matrix, growth factors, cytokines, stem cells or drugs to the fistula tract.

CONCLUSION

To date no study matches fistulotomy with regard to long-term fistula eradication rate. This is probably due to implant extrusion, inadequate track preparation or an unsuitable material. Future techniques need to address all these issues to ensure success. Success should be validated by MRI or long-term follow-up.

Case report: Treatment of rectovaginal fistula with Bioglue(®)

INTRODUCTION

Rectovaginal fistulas have a multitude of causes and it is well known that obstetric and gynecological problems form a large part of these causes such as our case.

PRESENTATION OF CASE

We present a 45-year-old female that presented with complaints of stool per vagina and was found to have a rectal vaginal fistula near the vaginal cuff from her previous uncomplicated vaginal hysterectomy. The patient was originally scheduled for a complex open abdominal surgery based on examination but underwent a sigmoidoscopy with vaginal examination and identified a small opening with minimal inflammation. The patient was treated with Bioglue(®) and had complete resolution of the fistula at follow-up.

DISCUSSION

There are numerous cases presented in the literature on the use of bioglue for anal fistulas and rectovaginal fistulas with multiple cases of success. However, in looking at the literature failure appears to be due to ongoing inflammation from the previous disease process.

CONCLUSION

Although the use of Bioglue(®) may not be suitable for all patients with rectovaginal fistulas, it offers yet another treatment modality for select patients.

Managing Perianal Crohn’s Disease

Perianal Crohn’s Disease (CD) is a significant cause of morbidity in CD patients. Accurate identification of perianal involvement requires advanced imaging techniques in addition to physical exam. Treatment of the disease is aimed at improving both the perianal and intestinal manifestations. Proper treatment depends upon the severity of the disease and combines current medical and surgical therapies to maximize response. The ability to improve perianal disease has grown significantly since the introduction of anti-TNF agents which are now a mainstay of treatment along with antibiotics and immunomodulators. New experimental therapies are limited by lack of research to support their use.