Porcine dermal collagen mesh (Permacol™) as a bioprosthesis in the ligation of intersphincteric tract (BioLIFT) procedure

Failure rates and complications of four sphincter-sparing techniques for the treatment of fistula-in-ano: a systematic review and network meta-analysis

BACKGROUND

Several techniques are available to reduce the risk of sphincter injury when treating anal fistula, such as ligation of the intersphincteric fistula tract (LIFT), video-assisted anal fistula treatment (VAAFT), fistula laser closure (FiLaC) and endoanal flap (EAF). The aim of this meta-analysis is to provide data on the safety, complications and failure of these techniques.

METHODS

Studies published after 2017, with patients undergoing at least one among LIFT, VAAFT, FiLaC and EAF for perianal fistula and providing data regarding failure, were retrieved from PubMed and EMBASE. Primary outcome was failure; other outcomes included continence disturbance and complications.

RESULTS

Forty-nine articles with 3520 patients were included. The failure rates were 28.6% (range 3.8-75) for LIFT, 22.3% (6.2-65.2) for VAAFT, 43.9% (11.1-80) for FiLaC and 25.9% (4.7-100) for EAF, with a mean follow-up of 35.4 (6-80.4), 32.4 (6-48), 31.6(6.3-60) and 42.4 (12-155) months. The available network meta-analysis on failure showed RD of -0.08 (95% CI - 0.58 to 0.42) comparing LIFT vs VAAFT and 0.30 (95% CI 0.03 to 0.58) comparing LIFT vs EAF. No patients undergoing VAAFT or FiLaC reported worsening continence, while for LIFT and EAF, the continence disturbance rate was 1.5% and 7.3%, respectively. No major complications were observed. The most common minor complications were pain (1.4%), bleeding (1.1%) and wound infection (1.2%). Overall, minor complication rates were 4.3% for LIFT, 7.2% for VAAFT, 10.2% for FiLaC and 6.2% for EAF. Crohn's disease was associated with a higher failure rate (39.5% vs 31.4%).

CONCLUSIONS

FiLaC, VAAFT, LIFT and EAF may represent a valid option in the treatment of anal fistula. VAAFT showed the lowest rate of failure but with no differences from network metanalysis. Wider homogeneous studies with long-term follow-up are necessary to obtain more robust data.

PROSPERO NUMBER

CRD42022375600.

The Use of Biologic Mesh for Repair of Perianal Fistulas

This is a case series of three patients who presented with complex anorectal fistulas. Each patient underwent repair of complex anorectal fistulas with biologic mesh. We will discuss each case and our institution's experience with this relatively new technique. This case series demonstrates the use of biologic mesh for the repair of complex anorectal fistulas. Three patients are discussed who underwent repair of perianal fistulas using ACell mesh by two separate surgeons. We will discuss the rationale for offering this treatment, as well as the advantages and disadvantages. The use of biologic mesh in perianal fistulas is a relatively new topic that needs further investigation. Perianal fistulas can be difficult to manage for both patients and surgeons. There are many options for repair, ranging from simple to complex. Biologic mesh for complex fistulas may be a useful option to avoid the morbidity of more complex repairs, such as flaps.

Efficacy and Safety of Sphincter-Preserving Surgery in the Treatment of Complex Anal Fistula: A Network Meta-Analysis

Background

There are many surgical methods of sphincter preservation in treating complex anal fistula, but the therapeutic effects of each operation are different. Therefore, this study aimed to compare the impact of other treatment methods through a network meta-analysis to evaluate the best sphincter preservation method for treating complex anal fistula.

Methods

We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Journal Database, and the Wanfang Database to collate randomized controlled trials on sphincter-preserving surgery for complex anal fistula.

Results

A total of 29 articles were included in this meta-analysis. The cure rates showed no statistically significant differences between any two interventions (P > 0.05). The recurrence rate results showed that the rate of patients after Fistulectomy was higher than others (P < 0.05). The incidence rate of complications showed that the incidence rate after fistulectomy treatment was higher than that of others (P < 0.05). The surface under the cumulative ranking (SUCRA) was used to arrange their advantages and disadvantages, and a larger SUCRA value indicates that the intervention may be more effective. The results showed that TROPIS may have the highest cure rate (SUCRA = 78.6%), stem cell transplantation (SCT) may have the lowest recurrence rate (SUCRA = 85.5%), and imLIFT may have the least complications (SUCRA = 88.2%).

Conclusion

According to the existing literature data, for patients with complex anal fistula, TROPIS may be the surgical method with the highest cure rate, SCT may be the treatment method with the lowest recurrence rate, and imLIFT may be the surgical method with the lowest incidence of postoperative complications.

Systematic Review Registration

PROSPERO, identifier: CRD42020221907.