Pre-operative assessment of anal fistulas using endoanal ultrasound

Impact of Preoperative Three-Dimensional Endoanal Ultrasound on the Surgical Outcome of Primary Fistula in Ano. A Multi-Center Observational Study of 253 Patients

PURPOSE

To evaluate the impact of preoperative three-dimensional endoanal ultrasound (3D-EAUS) on the clinical outcome of anal fistula surgery.

METHODS

The research consisted of multi-center retrospective case-control study including 253 consecutive adult patients undergoing surgery for confirmed or suspected primary fistula in ano who had undergone preoperative 3D-EAUS evaluation between January 2011 and January 2021. Main outcome measures were the concordance (K value) between ultrasound results and surgery in the identification of fistulas internal openings, primary tracts and secondary extensions and the 6 and 12 months success rate in patients with concordant and discordant findings.

RESULTS

A good agreement in the identification of the main fistulas characteristics between ultrasound results and operative findings was found. A significant difference (P < .0001; Fisher's exact test) in the success rate was found between patients with concordant and discordant ultrasound results and operative findings in identification or location of internal opening. Particularly, all the 11 (4.8%) patients with discordant results experimented a failure of the surgical procedure at 6 months follow-up. At re-operation, the shift from discordant to concordant results was associated with an 81.8% 12 months success-rate.

CONCLUSION

The three-dimensional endoanal ultrasound preoperative evaluation may have a relevant impact on the outcome of a defined group of patients undergoing surgery for anal fistula, since the careful evaluation of ultrasound results could simplify the internal orifice intra-operative detection and improve the success rate.

Management of patients with complex perianal fistulas in Crohn's disease: Optimal patient flow in the Italian clinical reality

Perianal fistulizing Crohn's disease (PFCD) is a common, disabling and aggressive phenotype that negatively impacts on the quality of life of affected patients. Its successful treatment is still a struggle for both physicians and patients. Significant advances in the management of this condition have occurred in the last two decades holding promise for a better future. This culminated into the concept of a collaborative multidisciplinary approach using the latest medical therapies combined with modern surgical and endoscopic techniques. Despite this, PFCD management and treatment have not been standardized yet. Thus the gastroenterologist and surgeon have to be familiar with several approaches and/or techniques. The positioning of each therapeutic option will certainly evolve with new data, but for the time being it should be driven by patient's characteristics, physician's preference and/or experience, costs and availability in local practice. Additionally, patient's perception of benefits and risks of treatment may differ from those of physicians and recognition of this difference is a starting point for difficult clinical decision-making. In this paper, a multidisciplinary group of Italian IBD experts explore and discuss current medical and surgical therapeutic options, highlighting areas of unmet needs in PFCD, with particular focus on the optimal patient flow within the Italian clinical reality.

Evaluation and management of perianal abscess and anal fistula: SICCR position statement

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Value of three-dimensional endoanal ultrasound scan (3D-EAUS) in preoperative assessment of fistula-in-ano

Objective

The aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound scan (3D-EAUS) in the pre-operative assessment of fistula-in-ano in identifying the fistula tract and comparing with findings at surgery in a South Asian cohort. A retrospective analysis of 87 patients with suspected fistula-in-ano who underwent pre-operative 3D-EAUS between January 2009 and January 2016 was carried out. All patients subsequently had surgical exploration under anaesthesia (EUA), irrespective of 3D-EAUS findings. The 3D-EAUS results were compared with the surgical findings to determine the accuracy of 3D-EAUS.

Results

A total of 86 (98.9%) patients (male = 75) were subsequently shown to have a fistula at surgical exploration and of them, 3D-EAUS detected a fistula in 79 (92%) patients. In this cohort, 3D-EAUS correctly predicted the surgical findings in (n = 61, 70.9%) patients with the highest accuracy being for transphincteric fistulae (87.1%). However, the overall concordance in our study was low with a kappa coefficient of 0.318. Additional findings such as sphincter defects were detected by the 3D-EAUS in 37 patients (internal sphincter defects-21, external sphincter defects-7, both-9) which were not evident at EUA. Therefore, 3D-EAUS had a good accuracy in selected types of fistulae and particularly useful in identifying sphincter defects before surgery.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4098-2) contains supplementary material, which is available to authorized users.

3D high-resolution anorectal manometry in patients with perianal fistulas: comparison with 3D-anal ultrasound

BACKGROUND

Perianal fistula surgery can damage the anal sphincters which may cause faecal incontinence. By measuring regional pressures, 3D-HRAM potentially provides better guidance for surgical strategy in patients with perianal fistulas. The aim was to measure regional anal pressures with 3D-HRAM and to compare these with 3D-EUS findings in patients with perianal fistulas.

METHODS

Consecutive patients with active perianal fistulas who underwent both 3D-EUS and 3D-HRAM at a clinic specialised in proctology were included. A group of 30 patients without fistulas served as controls. Data regarding demographics, complaints, previous perianal surgical procedures and obstetric history were collected. The mean and regional anal pressures were measured with 3D-HRAM. Fistula tract areas detected with 3D-EUS were analysed with 3D-HRAM by visual coding and the regional pressures of the corresponding and surrounding area of the fistula tract areas were measured. The study was granted by the VUmc Medical Ethical Committee.

RESULTS

Forty patients (21 males, mean age 47) were included. Four patients had a primary fistula, 19 were previously treated with a seton/abscess drainage and 17 had a recurrence after previously performed fistula surgery. On 3D-HRAM, 24 (60%) fistula tract areas were good and 8 (20%) moderately visible. All but 7 (18%) patients had normal mean resting pressures. The mean resting pressure of the fistula tract area was significantly lower compared to the surrounding area (47 vs. 76 mmHg; p < 0.0001). Only 2 (5%) patients had a regional mean resting pressure < 10 mmHg of the fistula tract area. Using a Δ mean resting pressure ≥ 30 mmHg difference between fistula tract area and non-fistula tract area as alternative cut-off, 21 (53%) patients were identified. In 6 patients 3D-HRAM was repeated after surgery: a local pressure drop was detected in one patient after fistulotomy with increased complaints of faecal incontinence.

CONCLUSIONS

Profound local anal pressure drops are found in the fistula tract areas in patients normal mean resting pressures. Fistulotomy may affect local sphincter pressure. This might influence surgical decision making in future.

Predictive factors for recurrence of cryptoglandular fistulae characterized by preoperative three-dimensional endoanal ultrasound

AIM

Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS).

METHOD

Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula.

RESULTS

There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2-118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2-51), P = 0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0-4.6), P = 0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%.

CONCLUSION

The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.

Endoanal ultrasound in perianal fistulae and abscesses

Endoanal ultrasound is a technique that provides imaging of the anal sphincters and its surrounding structures as well as the pelvic floor. However, endoanal magnetic resonance imaging (MRI) is preferred by most physicians, although costs are higher and demand easily outgrows availability. Endoanal ultrasound is an accurate imaging modality delineating anatomy of both cryptoglandular as well as Crohn perianal fistula and abscess. Endoanal ultrasound is comparable with examination under anesthesia and equally sensitive as endoanal MRI in fistula detection. When fistula tracts or abscesses are located above the puborectal muscle, an additional endoanal MRI should be performed. Preoperative imaging is advocated in recurrent cryptoglandular fistula because a more complex pattern can be expected. Endoanal ultrasound can help avoid missing tracts during surgery, lowering the chance for the fistula to persist or recur. It can easily be performed in an outpatient setting and endosonographic skills are quickly incremented. Costs are low and endoanal ultrasound has the potential to improve outcome of patients with both cryptoglandular and fistulizing Crohn disease; therefore, it values more attention.

Impact of three-dimensional endoanal ultrasound on the outcome of anal fistula surgery: a prospective cohort study

AIM

The aim of the study was to evaluate the impact of three-dimensional endoanal ultrasound (3D-EAUS) on postoperative outcome in patients with anal fistula.

METHOD

This prospective study compared clinical and functional outcomes of patients with and without preoperative 3D-EAUS examination 1 year after anal fistula surgery. Patients were prospectively followed and evaluated by a standardized protocol including physical examination, the Wexner Incontinence Score (WIS) and anorectal manometry, at baseline and 1 year after surgery.

RESULTS

A total of 196 patients were enrolled. There were no significant differences in demographic and operative parameters, except for operation time, between the two groups. At 1 year follow-up, the overall recurrence rates were 8.8% (9/102) in the 3D-EAUS group and 13.8% (13/94) in the examination under anaesthesia (EUA) group. In the subgroup of patients with complex fistulae, the recurrence rate was numerically lower in the 3D-EAUS group (12.8% vs 22.5%; P = 0.26). The WIS in the EUA group significantly worsened (0.35 ± 0.94 vs 1.07 ± 1.59; P = 0.003) with a decreased the number of fully continent patients (82.5% vs 55%; P = 0.008) while neither the WIS nor the proportion of fully continent patients changed in the 3D-EAUS group. Fewer patients in the 3D-EAUS group developed incontinence postoperatively (6.7% vs 33.3%; P = 0.012) and they had better maximum resting pressure and maximum squeeze pressure than the EUA group.

CONCLUSIONS

Preoperative use of 3D-EAUS had a favourable impact on the outcome of surgical treatment for anal fistulae, especially in those with complex anal fistula. It should be routinely used in the clinical setting.

Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis

PURPOSE

The aim of this study was to evaluate the accuracy of tridimensional endoanal ultrasound (3D-EAUS) in the diagnosis of perianal sepsis comparing the results with the surgical findings, considered as reference standard.

METHODS

From January 2009 to January 2013, all the patients referred for the assessment and treatment of perianal sepsis with suspected anorectal origin were enrolled in the study. All patients gave informed written consent. Prior to surgery, all the patients underwent anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS. Surgery was performed by a colorectal surgeon blinded to the 3D-EAUS results.

RESULTS

A total of 212 patients with suspected perianal suppurations were assessed during the study period. In 12 patients, the H2O2-enhanced 3D-EAUS was not performed, and so, they were excluded from the study. Very good agreement between 3D-EAUS and examination under anesthesia (EUA) in the classification of primary fistula tracts (kappa = 0.93) and in the identification of fistula internal opening (kappa = 0.97) was found. There was a good concordance (kappa = 0.71) between 3D-EAUS and surgery in the detection of fistula secondary extensions. The overall sensitivity and specificity of 3D-EAUS in the diagnosis of perianal sepsis were 98.3 and 91.3% respectively.

CONCLUSION

3D-EAUS is a safe and reliable technique in the assessment of perianal sepsis. It may assist the surgeon in delineating the fistula tract anatomy and in determining the origin of sepsis, supporting the preoperative planning of definitive and appropriate surgical therapy.

Hemorrhoids and fistulas: new solutions to old problems

Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.

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.

Comparison of preoperative endoanal ultrasonography with intraoperative findings for fistula in ano

BACKGROUND

Fistula in ano is a common benign anal condition seen in surgical practice. If fistula anatomy is incorrectly delineated or an occult abscess is missed, there is a risk of incomplete healing, recurrence of the fistula, or even iatrogenic sphincter injury from surgery resulting in anal incontinence. Therefore, an imaging modality ideally would provide accurate information that can be used to delineate the tract(s) prior to surgery. The aim of this study was to determine the accuracy of endoanal ultrasonography (EAUS) during the preoperative assessment of anal fistula tracts in respect to the type of the fistula, horseshoeing of the tract, and localized collections.

METHODS

A consecutive series of 64 patients underwent preoperative EAUS assessment of the fistula. All patients subsequently had surgical exploration under anesthesia irrespective of findings at sonography. The operative findings were compared with the US findings. The association between EAUS and operative findings was determined by nonparametric Spearman's rank correlation (rho) coefficient test.

RESULTS

The male/female ratio was 58:6. Mean age was 41.53 years (range 11-60 years). EAUS detected the fistula tract in most (95.3%). On EAUS, the primary tract was transsphincteric, intersphincteric, or superficial in 34 (53.1%), 25 (39.1%), and 2 (3.2%) patients, respectively. Localized collections were identified in 24 of the 64 (37.5%) patients (rho = 0.986). The fluid collection locations were 12 intersphincteric, 7 superficial, 4 infralevator, and 1 supralevator. At surgery, 38 (59.4%) fistula tracts were transsphincteric, 17 (26.6%) intersphincteric, 5 (7.8%) suprasphincteric, and 3 (4.7%) superficial. US correctly predicted the primary tract in 71.9% of fistulas (rho = 0.5).

CONCLUSIONS

EAUS has high accuracy for predicting the type of anal fistula and for detecting associated sepsis/fluid collections. This information is useful for preoperative planning of fistula treatment. EAUS therefore is an accurate test for determining fistula anatomy prior to surgery.

The role of 3-dimensional anorectal ultrasonography in the assessment of anterior transsphincteric fistula

PURPOSE

The aim of this study was to evaluate the role of 3-dimensional anorectal ultrasonography in the choice of surgical technique according to the position of the fistulous tract in patients with anterior transsphincteric anal fistula.

METHODS

A total of 33 patients (18 male) with anterior transsphincteric fistulas were evaluated by ultrasonography. The length of the external and internal anal sphincters, the position of the internal opening, the length of the compromised sphincter, and the percentage of sphincter muscle to be transected during surgery were measured, compared between sexes, and used in planning the surgery. Postoperative incontinence symptoms were quantified with a Wexner score.

RESULTS

The external and internal sphincters were longer and the position of the internal opening was higher in males. The position where the tract crossed the external sphincter was in both sexes, but the percentage of compromised muscle was higher in females because of the smaller length of the external sphincter. Seton placement followed by fistulotomy or advanced flap repair were indicated in 11 of 18 males and 13 of 15 females as the tract crossed the external sphincter above 50.0%. The mean postoperative follow-up was 12 months. Overall, minor fecal incontinence symptoms were identified in 16 (48.0%) patients. Of these, 11 (73.0%) females and 5 (28.0%) males had a mean incontinence score of 2.9 and 3.0, respectively.

CONCLUSIONS

Three-dimensional ultrasonography was shown to be useful in the preoperative assessment of anterior transsphincteric fistulas by quantifying the length of muscle to be transected, contributing to the choice of a safe treatment approach and to the reduction of the rate of postoperative continence disorders.

Current techniques in imaging of fistula in ano: three-dimensional endoanal ultrasound and magnetic resonance imaging

Perianal fistula is an abnormal communication between the anal canal and perianal skin. The majority of perianal fistulous disease results from either cryptoglandular inflammation or Crohn's disease. These groups differ in pathophysiology, prognosis, and strategies for imaging and treatment. Endoanal ultrasound and magnetic resonance imaging represent current imaging strategies for evaluating perianal fistulas and may be used alone or in combination. The use of three-dimensional technique and peroxide fistulography optimize the ultrasound evaluation of perianal fistula. The use of multiple imaging planes and sequences including fat suppression and contrast enhancement optimize the magnetic resonance imaging protocol. Examples of the imaging appearance of perianal fistulas and a proposed flowchart for imaging modality selection are provided.

Prognostic value of endoanal ultrasound for fistula-in-ano: a retrospective analysis

PURPOSE

This study was designed to assess whether preoperative endoanal ultrasound plays a prognostic role in the surgical outcome of anal fistula.

METHODS

A retrospective review was conducted at a single institution.

RESULTS

Sixty-nine patients underwent 83 studies. Indications for endoanal ultrasound included complex fistulas and tracts, multiple external openings, recurrent fistulas, and/or failed previous surgical intervention. Mean age was 51.7 years. Fifty-three patients (77 percent) were men. Mean duration of symptoms was 3.1 years. Forty-nine patients (71 percent) had undergone previous surgical intervention to eradicate sepsis or fistula. Sixty patients (87 percent) underwent surgical interventions and were divided into two groups: Group A (73.3 percent), concordance with ultrasound findings; and Group B (26.7 percent), nonconcordance. Mean follow-up in the surgical group was 15.6 months. Measured outcome was total number of operations per patient and failure rate of primary surgical intervention. No difference was noted in mean total number of operations between Group A (1.57) and Group B (1.69) (P = 0.71). There was a statistically nonsignificant trend toward a higher failure rate of the primary intervention in the nonconcordance group [failure rate 18.2 percent in Group A vs. 25 percent in Group B (P = 0.72)].

CONCLUSIONS

The findings and accuracy of preoperative endoanal ultrasound did not influence postoperative outcome.

The role of transperineal ultrasonography in the assessment of the internal opening of cryptogenic anal fistula

PURPOSE

The aim of this study was to assess the reliability of transperineal ultrasonography (TPUS) in the pre-operative identification of the internal opening of anal fistulas compared to conventional proctological examination and operative findings.

METHODS

Forty-three patients with anal fistula were assessed by TPUS with and without the use of hydrogen-peroxide injection (E-TPUS) in an attempt to identify the internal opening. Results were compared to preoperative conventional examination and operative findings.

RESULTS

Operative assessment showed an anterior internal opening in 29 patients (67.4%) and a posterior opening in 14 (32.6%). Compared to the operative findings, the agreement rate for the identification of the internal opening was 74.4% for physical examination alone, 93.0% for TPUS and 90.7% for E-TPUS. Physical examination was less accurate in detecting the internal opening than both TPUS (p=0.014) and E-TPUS (p=0.026).

CONCLUSIONS

TPUS and E-TPUS are superior to physical examination in the identification of internal openings in anal fistulas. Hydrogen peroxide injection does not provide additional advantages.

The use of intra-operative endo-anal ultrasound in perianal disease

INTRODUCTION

Endoanal ultrasound (EAUS) has demonstrated high sensitivity and specificity for the structural imaging of anorectal pathology. This study prospectively assessed the impact of intra-operative EAUS on the surgical management of perianal disease.

METHODS

EAUS was performed prior to and after examination under anaesthesia (EUA) in a consecutive series of patients with perianal disease. The impact of EAUS on the surgery performed was identified.

RESULTS

Forty-three procedures have been performed in 38 patients (21 male, 17 female; mean age 42.7 years, range 6-76 years) over a three year period. Pathologies encountered were fistula-in-ano (42%), fissure-in-ano (26%), complicated perianal sepsis (16%) and carcinoma (5%). No specific abnormality was identified in 5 symptomatic patients (12%). Four patients with fissures had undergone previous sphincterotomy. In 22 cases (51.2%) the EAUS findings affected the surgical management (extent of muscle above a fistula 9 cases, extent of sphincterotomy 7 cases, site of sepsis identified 2 cases, exclusion of sepsis 2 cases, assessment of cancer resectability 1 case, biopsy of intersphincteric lesion 1 case).

CONCLUSION

Intra-operative EAUS accurately identifies perianal disease and influences the surgical procedure performed. While not essential, it is a useful adjunct especially in recurrent perianal sepsis, undiagnosed anorectal pain and anal fissure.

Endosonographic imaging of anorectal diseases

OBJECTIVE

The normal sonographic anatomy of the anorectum, sonographic findings of anorectal diseases, and indications and limitations of endosonography compared with magnetic resonance imaging are reviewed. Methods. Endosonographic imaging was performed with a Siemens (Erlangen, Germany) FI 400 ultrasound scanner with an end-fire 7.5-MHz biplane endorectal probe and a B-K Medical (Sandhoften, Denmark) scanner with an 1850 axial-type side-fire 5.0- to 10.0-MHz rotating endoscopic probe.

RESULTS

Rectal carcinoma appears on endorectal sonography as a low-echogenicity lesion that abruptly interrupts the normal sequence of layers. The internal anal sphincter is seen very clearly on endoanal sonography, and it is easy to appreciate atrophy and small tears of this sphincter. Endoanal sonography cannot accurately show thinning of the external anal sphincter. Peroxide-enhanced endoanal sonography is especially useful for patients with recurrent perianal fistulas in whom scarring should be distinguished from recurrent fistulas and detection of the internal opening. However, sonography does not provide an adequate deep and global display of all adjacent pelvic and perineal spaces.

CONCLUSIONS

Endosonography can accurately stage primary rectal tumors and assess the internal anal sphincter. Peroxide-enhanced 3-dimensional imaging can increase the utility of endoanal sonography in detection and characterization of perianal fistulas and planning of optimal therapy. However, magnetic resonance imaging can be used a complementary modality to endosonography, especially for evaluation of external anal sphincter atrophy and deep pelvic inflammation.

Fibrin glue in the management of anal fistulae

OBJECTIVE

Fibrin glue has been used as a sphincter sparing approach for the treatment of anal fistulae for two decades. However, there is uncertainty about its short and long-term efficacy. The objective of this review was to ascertain the role of fibrin glue in the management of anal fistulae, including assessment of recurrence rates, continence disturbance and other complications.

METHODS

We searched Medline (January 1966 to February 2004), the Cochrane database, and EMBASE using the terms anal fistulae, fistula-in-ano, and fibrin glue. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. A systematic review of all articles relating to the use of fibrin glue in the treatment of anal fistulae was performed. This included 19 studies. Reviewers performed data extraction independently. Outcomes evaluated included recurrence rates, continence disturbance, septic complications, adverse drug reactions, and duration of follow-up. Heterogeneity of the clinical trials made direct comparisons difficult and meta-analysis impossible.

RESULTS

The success rates reported in published studies range from 0% to 100%. Differences in patient selection (including fistula aetiology and type), treatment protocols, and follow-up duration may contribute to such diverse results.

CONCLUSIONS

Fibrin glue is simple to use, has a minimal morbidity and should not affect later treatment options in the event of its failure. It is therefore theoretically attractive as a first line treatment in the management of those types of anal fistula in which it has been shown to work. However, further research into 'biological' glues is merited and these subject to randomised controlled study.