Repair of fistulas-in-ano using autologous fibrin tissue adhesive

Current Therapy of Cryptoglandular Anal Fistula: Gold Standards and Alternative Methods

Cryptoglandular anal fistulas are one of the most common colorectal diseases and occur with an incidence of about 20/100,000. Anal fistulas are defined as an inflammatory junction between the anal canal and the perianal skin. They develop from an abscess or chronic infection of the anorectum. Surgical treatment of the disease is the method of choice. Even when treating an acute abscess, its cause should be sought at the same time. If there is a connection to the anal canal without affecting relevant parts of the sphincter muscles, primary fistulotomy should be performed. If larger parts of the sphincter muscle are involved, the insertion of a seton drain is usually useful. There are essentially two recommendations for the elective treatment of cryptoglandular anal fistulas. Distal fistulas should be excised, with the proviso that as little sphincter muscle as possible is sacrificed. In the case of highly proximally located and complex fistulas, sphincter-preserving surgical techniques should be used. In this case, the method of choice is the mucosal or advancement flap. Alternatively, clips, fibrin injections, fistula plugs, fistula ligatures, or laser-based procedures are described in the literature. In the case of intermediate fistulas, a fistulectomy with primary sphincter reconstruction can be useful. Every operation is carried out as a compromise between definitive healing of the fistula and a potential risk to the patient's continence. It is often difficult to make a reliable prognosis about the continence function to be expected postoperatively. In addition to the fistula morphology, particular attention should be paid to whether previous proctological operations have already been performed, the gender of the patient, and whether there are pre-existing sphincter dysfunctions. Since the surgeon's expertise plays a decisive role in the success of the treatment, the procedure should be carried out in a specialist proctological centre, especially in the case of complex fistulas or in the case of a condition after previous operations. In addition to the classic procedures, such as fistulectomy or the plastic fistula closure, this article examines alternative methods and their areas of application.

Hot topics in global perianal fistula research: A scopus-based bibliometric analysis

BACKGROUND

The number of citations a scientific paper has received indicates its impact within any medical field. We performed a bibliometric analysis to highlight the key topics of the most frequently cited 100 articles on perianal fistula to determine the advances in this field.

METHODS

The Scopus database was searched from 1960 to 2018 using the search terms "perianal fistula" or "anal fistula" or "fistula in ano" or "anal fistulae" or "anorectal fistulae" including full articles. The topic, year of publication, publishing journal, country of origin, institution, and department of the first author were analyzed.

RESULTS

The median number of citations for the top 100 of 3431 eligible papers, ranked in order of the number of citations, was 100 (range: 65-811), and the number of citations per year was 7.5 (range: 3.8-40.1). The most-cited paper (by Parks et al in 1976; 811citations) focused on the classification of perianal fistula. The institution with the highest number of publications was St Mark's Hospital, London, UK. The most-studied topic was surgical management (n = 47). The country and the decade with the greatest number of publications in this field were the USA (n = 34) and the 2000s (n = 50), respectively.

CONCLUSION

The 100 most frequently cited manuscripts showed that surgical management had the greatest impact on the study of perianal fistula. This citation analysis provides a reference of what could be considered the most classic papers on perianal fistula, and may serve as a reference for researchers and clinicians as to what constitutes a citable paper in this field.

Advances in Perianal Disease Associated with Crohn's Disease-Evolving Approaches

Perianal diseases, common complications of Crohn's disease, are difficult to diagnose/manage. Patients with perianal Crohn's disease suffer from persistent pain and drainage, recurrent perianal sepsis, impaired quality of life, and financial burden. Conventional medical and surgical therapies carry risk of infection, myelosuppression, incontinence, disease recurrence. Although the phenotype of Crohn's disease has been extensively studied, reported outcomes are inconsistent. Endoanal ultrasonography is also becoming popular because of low cost and ability to acquire images in real time. Emerging management strategies for treatment including laser therapy, local injection of agents, use of hyperbaric oxygen, and stem cell therapy, have demonstrated efficacy.

Permacol™ Collagen Paste Injection in Anal Fistula Treatment: A Retrospective Study with One-Year Follow-Up

INTRODUCTION

This study aimed to evaluate the applicability, safety, results, and functional performance of Permacol™ collagen paste injection in patients with an anal fistula.

METHODS

Thirty-one patients with anal fistula underwent Permacol™ collagen paste injection between February 2015 and February 2017. The patients were followed up for a total of 12 months with recovery conditions monitored at intervals of 3, 6, and 12 months. Preoperative insertion of seton was performed in 15 patients for a period of 6-8 weeks and 2 patients for a period of 12 weeks.

RESULTS

A trans-sphincteric anal fistula was present in 20 patients and an intersphincteric fistula was present in 11 patients. There was a recurrence in 7 patients (22.5%): 1 patient (3.2%) after 1-month follow-up, 3 patients (9.7%) after 3-month follow-up, 2 patients (6.5%) after 6-month follow-up, and 1 patient (3.2%) after 12-month follow-up. A complete recovery was observed in 24 (77.5%) patients after a 12-month follow-up. The mean Fecal Incontinence Severity Index score was 0.29 ± 0.64 preoperatively and 0.55 ± 1.03 after 12 months.

CONCLUSION

In this study, we show that treatment of patients with an anal fistula by injection of Permacol™ is a safe and successful method that does not compromise continence.

Permacol™ collagen paste injection for the treatment of complex anal fistula: 1-year follow-up

BACKGROUND

Optimal surgical treatment for anal fistula should result in healing of the fistula track and preserve anal continence. The aim of this study was to evaluate Permacol™ collagen paste (Covidien plc, Gosport, Hampshire, UK) injection for the treatment of complex anal fistulas, reporting feasibility, safety, outcome and functional results.

METHODS

Between May 2013 and December 2014, 21 consecutive patients underwent Permacol paste injection for complex anal fistula at our institutions. All patients underwent fistulectomy and seton placement 6-8 weeks before Permacol™ paste injection. Follow-up duration was 12 months.

RESULTS

Eighteen patients (85.7%) had a high transsphincteric anal fistula, and three female patients (14.3%) had an anterior transsphincteric fistula. Fistulas were recurrent in three patients (14.3%). Seven patients (33%) had a fistula with multiple tracts. After a follow-up of 12 months, ten patients were considered healed (overall success rate 47.6%). The mean preoperative FISI score was 0.33 ± 0.57 and 0.61 ± 1.02 after 12 months.

CONCLUSIONS

Permacol™ paste injection was safe and effective in some patients with complex anal fistula without compromising continence.

Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review

AIM

Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.

METHOD

A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken.

RESULTS

We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study.

CONCLUSION

Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.

Complex anal fistula remains a challenge for colorectal surgeon

AIM

Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas.

MATERIAL AND METHODS

A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm.

RESULTS

The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities.

CONCLUSIONS

Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.

Biomaterials in the treatment of anal fistula: hope or hype?

Anal fistula (AF) presents a chronic problem for patients and colorectal surgeons alike. Surgical treatment may result in impairment of continence and long-term risk of recurrence. Treatment options for AFs vary according to their location and complexity. The ideal approach should result in low recurrence rates and minimal impact on continence. New technical approaches involving biologically derived products such as biological mesh, fibrin glue, fistula plug, and stem cells have been applied in the treatment of AF to improve outcomes and decrease recurrence rates and the risk of fecal incontinence. In this review, we will highlight the current evidence and describe our personal experience with these novel approaches.

Endoscopic treatment of Crohn's complications

The progression to fistula and strictures is part of the natural history of Crohn's disease (CD) and these complications negatively affect the quality of life of CD patients. Surgery is the traditional treatment of CD strictures. However, due the chronicity of the inflammatory process and the associated fibrosis, postoperative recurrence occurs frequently. The lack of specific drug to treat fibrotic strictures and their irreversible nature has drawn the attention to less invasive and bowel-sparing therapeutic modalities. Endoluminal therapies may provide effective option in relieving symptoms associated with CD complications and reduce the need for repeated surgery with substantial clinical benefit. This review will discuss the current use and efficacy of the endoscopic treatment of CD complications. New endoscopic modalities and recent advances will be also evaluated.

Improving the outcome of fistulising Crohn's disease

Fistulas are a frequent manifestation of Crohn's disease (CD) and can result in considerable morbidity. Approximately 35% of all patients with CD will experience one fistula episode during their disease course of which 54% is perianal. The major symptoms of patients with perianal fistulas are constant anal pain, the formation of painful swellings around the anus and continuous discharge of pus and/or blood from the external fistula opening. The exact aetiology of perianal fistulas in CD patients remains unclear, but it is thought that a penetrating ulcer in the rectal mucosa caused by active CD forms an abnormal passage between the epithelial lining of the rectum and the perianal skin. Genetic, microbiological and immunological factors seem to play important roles in this process. Although the incidence of perianal fistulas in patients with CD is quite high, an effective treatment is not yet discovered. In this review all available medical and surgical therapies are discussed and new treatment options and research targets will be highlighted.

Fistulectomy with primary sphincter reconstruction in the treatment of high transsphincteric anal fistulas

PURPOSE

The treatment of transsphincteric anal fistulas is a challenge between recurrence rate and incontinence. Many surgical and conservative procedures have been described in the treatment of anal fistulas. Fistulectomy and primary sphincter reconstruction (FPSR) has not gained great popularity in this field due to the risk of sphincter damage. The aim of this study is to evaluate FPSR in the treatment of transsphincteric fistulas.

METHODS

We retrospectively analyzed 50 patients with high transsphincteric fistulas of cryptoglandular origin that were treated with FPSR between 2005 and 2008. Preoperative assessment included physical and proctologic examination. Continence and pain scores were evaluated preoperatively and postoperatively.

RESULTS

In our 50 patients, 22 patients (44 %) had a previous proctologic operation and 11 patients (22 %) presented with recurrent fistulas. The fistulas existed for an average of 8 months. The operation time was 28 ± 16 min. Mean follow-up was 22± months. The fistula healed in 44 patients (88 %) who developed no recurrence. In five patients (10 %), the fistula healed, but they developed a recurrence in the observation period. In one patient (2 %), the fistula did not heal. Three patients developed low-grade incontinence for flatus, and one patient with 2° incontinence improved. Preoperatively and postoperatively calculated continence and pain scores showed a slight but significant elevation in the Clinical Continence Score, the German Society of Coloproctology Score showed no significant difference, and preexisting pain was reduced significantly by surgery.

CONCLUSIONS

FPSR is a safe surgical procedure for the treatment of high transsphincteric anal fistula. The primary healing rate is high with a low risk of recurrence or incontinence.

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.

Surgical treatment of anorectal crohn disease

Crohn disease involves the perineum and rectum in approximately one-third of patients. Symptoms can range from mild, including skin tags and hemorrhoids, to unremitting and severe, requiring a proctectomy in a small, but significant, portion. Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation. Careful diagnosis, including magnetic resonance imaging or endorectal ultrasound with examination under anesthesia and aggressive medical management, usually with a tumor necrosis factor-alpha, is critical to success. Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure. All suffer from decreased efficacy in patients with Crohn disease. In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended, as iatrogenic injury and poor wound healing are common in that scenario.

Gore BioA Fistula Plug in the treatment of high anal fistulas--initial results from a German multicenter-study

Background: Treatment of high anal fistulas may be associated with a high risk of continence disorders. Beside traditional procedure of flap-reconstruction the occlusion of the fistula tract using fistula-plugs offers a new sphincter-saving treatment option. In this study for the first time results from Germany are described.

Patients and method: 40 patients (30 male, 10 female, age 51±12 years) underwent closure of a high trans-sphincteric (n=28) or supra-sphincteric (n=12) fistula with Gore BioA Fistula Plug^® in three surgical departments. The surgical procedures had been performed by five colorectal surgeons. Four patients had Crohn’s disease. Preoperatively 33 patients were completely continent; seven patients complained of minor continence disorders. Treatment of the patients was performed on a intent-to-treat basis and evaluation of the results was retrospective using pooled data from each center.

Results: Postoperatively one patient developed an abscess, which had to be managed surgically. In two patients the plug had fallen out within the first two weeks postoperatively. Six months after surgery the fistula has been healed in 20 patients (50.0%). Three additional fistulas healed after 7, 9 rsp. 12 months. The overall healing-rate was 57.5% (23/40). The healing rate differs considerably between the surgeons from 0 to 75% and depends on the number of previous interventions. In patients having only drainage of the abscess success occurred in 63.6% (14/22) whereas in patients after one or more flap fistula reconstruction the healing rate decreased slightly to 50% (9/18). No patient complained about any impairment of his preoperative continence status.

Conclusion: By occlusion of high anal fistulas with a plug technique definitive healing could be achieved in nearly every second patients. Previous surgery seems to have a negative impact on success rate. We have not observed any negative impact on anal continence. From that point of view anal fistula plugs might be discussed as a treatment option for high anal fistulas, but further studies are needed to gain conclusive evidence.

Endoanal ultrasonography-assisted percutaneous transperineal management of anorectal sepsis

PURPOSE

We aimed to analyze the feasibility and efficacy of a new transperineal access to treat anorectal sepsis (fistulae and abscesses) under endoanal ultrasonography guidance.

METHODS

Twenty-five patients (80% Crohn disease) were included retrospectively. Twenty-one patients had fistulae (perianal, urethroanal, and anovaginal) treated by injection of heterologous fibrin glue and cyanoacrylate. Four patients with abscesses were treated by irrigation-injection of normal saline solution and an aminoglycoside antibiotic.

RESULTS

Twenty-five patients underwent 32 treatment sessions. At 4 weeks' evaluation, 19 patients (90.5%) with anal fistulae ultimately achieved a 4-week short-term success. Of these, 5 patients (26%) showed resolution of symptoms and persistent occlusion of the fistula track at long-term follow-up (>6 mo). At 4-week follow-up, the treatment of abscesses was successful in 3 of 4 cases. However, a relapse was observed in 2 cases after a mean period of 3 months. No serious adverse events were observed.

CONCLUSIONS

Endoanal ultrasonography-assisted percutaneous transperineal injection represents a sphincter-sparing alternative to the surgical route, with interesting outcomes and excellent tolerability for the treatment of anorectal sepsis.

Ligation of intersphincteric fistula tract compared with advancement flap for complex anorectal fistulas requiring initial seton drainage

BACKGROUND

The ligation of intersphincteric fistula tract (LIFT) is a relatively new surgical technique for treating complex anorectal fistulas.

METHODS

LIFT was compared with anorectal advancement flap management (ARAF) of complex anorectal fistulas requiring previous seton drainage. Crohn's patients were excluded. Patients with no confirmed recurrent sepsis after 6 months were randomized to day surgery performance of LIFT (25; 17 male) or ARAF (14; 10 male) with removal of the seton. Outcome measures included recurrences, surgical time, complications, hospital readmissions, and fecal incontinence.

RESULTS

LIFT was 32.5 minutes shorter than ARAF (P < .001). Complications were similar, with no hospital readmissions. Return to normal activities was 1 week for LIFT patients, 2 weeks for ARAF patients (P = .016). At 19 months there were 3 recurrences (2 in the LIFT group). One ARAF patient had minor incontinence.

CONCLUSIONS

The LIFT procedure was simple, safe, shorter, and patients returned to work earlier. All patients had preliminary seton drainage, possibly contributing to the low recurrence rates.

Evolution of treatment of fistula in ano

BACKGROUND

Fistula-in-ano is a common medical problem affecting thousands of patients annually. In the past, the options for treatment of fistula-in-ano were limited to fistulotomy and/or seton placement. Current treatment options also include muscle-sparing techniques such as a dermal island flap, endorectal advancement flap, fibrin sealent injection, anal fistula plug, and most recently ligation of the intersphincteric fistula tract (procedure). This study seeks to evaluate types and time trends for treatment of fistula-in-ano.

METHODS

A retrospective review from 1975 to 2009 was performed. Data were collected and sorted into 5-year increments for type and time trends of treatment. Fistulotomy and partial fistulotomy were grouped as cutting procedures. Seton placement, fibrin sealant, dermal flap, endorectal flap, and fistula plug were grouped as noncutting procedures. Statistical analysis was performed for each time period to determine trends.

RESULTS

With institutional review board approval, the records of 2,267 fistula operations available for analysis were included. Most of the patients were men (74 vs. 26%). Cutting procedures comprised 66.6% (n = 1510) of all procedures. Noncutting procedures were utilized in 33.4% (n = 757), including Seton placement alone 370 (16.3%), fibrin sealant 168 (7.4%), dermal or endorectal flap 147 (6.5%), and fistula plug 72 (3.2%). The distribution of operations grouped in 5-year intervals is as follows: 1975-1979, 78 cutting and one noncutting; 1980-1984, 170 cutting and 10 noncutting; 1985-1989, 54 cutting and five noncutting; 1990-1994, 37 cutting and six noncutting; 1995-1999, 367 cutting and 167 noncutting; 2000-2004, 514 cutting and 283 noncutting; 2005-2009, 290 cutting and 285 noncutting. The percentage of cutting and noncutting procedures significantly differed over time, with cutting procedures decreasing and noncutting procedures increasing proportionally (χ(2) linear-by-linear association, p < 0.05).

CONCLUSIONS

Fistula-in-ano remains a common complex disease process. Its treatment has evolved to include a variety of noncutting techniques in addition to traditional fistulotomy. With the advent of more sphincter-sparing techniques, the number of patients undergoing fistulotomy should continue to decrease over time. Surgeons should become familiar with various surgical techniques so the treatment can be tailored to the patient.

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.

Long-term results of surgery plus fibrin sealant for anal fistula

AIM

The long-term recurrence rate of fibrin glue treatment was analysed in patients with trans-sphincteric cryptoglandular fistula operated by a two-phase procedure: (i) fistulectomy with seton placement; (ii) fibrin sealant (Tissucol Duo®, Baxter) insertion in the track.

METHOD

Clinical data were collected prospectively for all patients operated between 2004 and 2010. The statistical association of clinical variables and recurrence was analysed and a disease-free curve was constructed using the Kaplan-Meier method.

RESULTS

Twenty-eight consecutive patients (mean age 48.3 ± 13.3 years; 22 men) were enrolled in the study. Middle and high trans-sphincteric fistulae were diagnosed in 20 (71.4%) and eight (28.6%) patients. Seven (25%) had secondary track formation. The mean interval between the first operation and the fibrin sealant treatment was 12.5 ± 7.6 months. There were no complications related to the procedure. Nine (32.1%, 95% CI 17.9-50.7%) patients developed recurrence between 3 and 27 months after fibrin sealant treatment. Disease-free curves showed that the highest probability of recurrence occurred in the first 2 years. No incontinence was found at a mean follow-up of 20.6 (3-60) months among the 67.8% patients with no evidence of recurrence.

CONCLUSION

Fibrin sealant is safe and simple. The healing rate is satisfactory without the risk of incontinence.

Long-term results of fibrin glue treatment for cryptogenic perianal fistulas: a multicenter study

BACKGROUND

Instillation of fibrin glue, a simple and safe procedure, has been shown to have a moderate short-term success rate in the treatment of cryptogenic perianal fistulas.

OBJECTIVE

This study aimed to assess the long-term outcome of this procedure.

DESIGN

This study included a retrospective chart review and telephone interviews.

SETTINGS

This study was conducted at 4 university-affiliated medical centers.

PATIENTS

Patients were included who underwent fibrin glue instillation for complex cryptogenic fistula between 2002 and 2003 within a prospective trial and had successful healing.

INTERVENTIONS

Fibrin glue was instilled for complex cryptogenic fistula.

MAIN OUTCOME MEASURES

The main outcome measure was long-term fistula healing.

RESULTS

Sixty patients participated in the initial trial; the fistulas in 32 of these patients were healed at 6 months. We have located and interviewed 23 (72%) of those patients. Seventeen (74%) patients remained disease free at a mean follow-up of 6.5 years. Six (26%) patients had variable degrees of recurrence; 4 needed further surgical intervention and 2 were treated with antibiotics only. Recurrent disease occurred at an average of 4.1 years (range, 11 mo to 6 y) from surgery, and on several occasions was at a different location in the perianal region. None of the patients experienced incontinence following the procedure.

LIMITATIONS

The retrospective nature of this long-term follow-up was a limitation. Twenty-eight percent of the potentially eligible patients were lost to long-term follow-up.

CONCLUSIONS

Short-term success of fibrin glue in the treatment of cryptogenic perianal fistula is predictive of long-term healing, but a quarter of those healed in the short term may develop recurrent symptoms in the long run. Injection of fibrin glue remains a safe and simple procedure and may preclude extensive surgery.

Autologous platelet-derived growth factors (platelet-rich plasma) as an adjunct to mucosal advancement flap in high cryptoglandular perianal fistulae: a pilot study

AIM

The aim of this study was to explore autologous platelet-rich plasma as an adjunct to the staged mucosal advancement flap in the treatment of perianal fistulae.

METHOD

Between February 2006 and May 2007, 10 patients with fistula tracts transversing from the middle-third or upper part of the anal sphincter were treated for at least 3 months with noncutting setons prior to definitive closure by autologous platelet-rich plasma as an adjunct to a mucosal advancement flap. Five patients smoked tobacco.

RESULTS

The study group consisted of six women and four men with a median age of 44 (range 30-75) years and a median follow up of 26 (range 17-32) months. One (10%) patient had a recurrent fistula. No new continence disorders developed after definitive treatment in both groups.

CONCLUSION

Platelet-rich plasma as an adjunct to a staged mucosal advancement flap for the treatment of perianal cryptoglandular fistulae is a promising treatment modality and seems to establish a high healing rate.

Fibrin glue in the management of complex anal fistula

CONTEXT

Management of complex anal fistulas is associated with the risk of sphincter injury and fecal incontinence. In recent years, fibrin glue has emerged as an alternative sphincter-preserving treatment for anal fistulas. To date, however, there is no consensus about the efficacy of the method.

OBJECTIVE

To specifically evaluate the fibrin glue injection in the management of complex cryptoglandular anal fistulas.

METHODS

We studied a series of patients with complex anal fistulas treated with fibrin glue between January 2005 and January 2007. Only patients with fistulas of cryptoglandular origin were analyzed. Patients with fistulas related to Crohn's disease, HIV or previous surgery were excluded from the study. Under spinal anesthesia, the fistulas were curetted and injected with fibrin glue. After treatment, patients were followed-up for 12 months.

RESULTS

Thirty-two patients were enrolled in the study. Two patients were lost to follow-up and were excluded. Out of the remaining 30 patients, only three healed successfully (10%). Among the 27 patients who failed to heal, 9 (33.3%) were diagnosed within the first postoperative month. In 13 patients (48.1%) the failure of treatment occurred in the period between 1 and 3 months, in 3 patients (11.1%) between 3 and 6 months, and in 2 patients (7.4%) between 6 and 9 months after surgery. No treatment-related complications were observed.

CONCLUSIONS

In this series, fibrin glue treatment for complex cryptoglandular anal fistulas achieved a very low healing rate. Our results do not support the use of fibrin glue as a first-line treatment for patients with this type of fistula.

Randomized controlled trial of minimally invasive surgery using acellular dermal matrix for complex anorectal fistula

AIM: To compare the efficacy and safety of acellular dermal matrix (ADM) bioprosthetic material and endorectal advancement flap (ERAF) in treatment of complex anorectal fistula.

METHODS: Ninety consecutive patients with complex anorectal fistulae admitted to Anorectal Surgical Department of First Affiliated Hospital, Xinjiang Medical University from March 2008 to July 2009, were enrolled in this study. Complex anorectal fistula was diagnosed following its clinical, radiographic, or endoscopic diagnostic criteria. Under spinal anesthesia, patients underwent identification and irrigation of the fistula tracts using hydrogen peroxide. ADM was securely sutured at the secondary opening to the primary opening using absorbable suture. Outcomes of ADM and ERAF closure were compared in terms of success rate, fecal incontinence rate, anorectal deformity rate, postoperative pain time, closure time and life quality score. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up examination was performed 2 d, 2, 4, 6, 12 wk, and 5 mo after surgery, respectively.

RESULTS: No patient was lost to follow-up. The overall success rate was 82.22% (37/45) 5.7 mo after surgery. ADM dislodgement occured in 5 patients (11.11%), abscess formation was found in 1 patient, and fistula recurred in 2 patients. Of the 13 patients with recurrent fistula using ERAF, 5 (11.11%) received surgical drainage because of abscess formation. The success rate, postoperative pain time and closure time of ADM were significantly higher than those of ERAF (P < 0.05). However, no difference was observed in fecal incontinence rate and anorectal deformity rate after treatment with ADM and ERAF.

CONCLUSION: Closure of fistula tract opening with ADM is an effective procedure for complex anorectal fistula. ADM should be considered a first line treatment for patients with complex anorectal fistula.

Treatment of post-prostatectomy rectourethral fistula with fibrin sealant (Quixil™) injection: a novel application

Rectourethral fistulas in adults is a rare but potentially devastating postoperative condition requiring complex and demanding surgery. Fibrin glue treatment has been used with some success in anal and rectovaginal fistulas, and in the case we present here this indication has been extended to a postoperative rectourethral fistula following radical prostatectomy. For the first time, to our knowledge, a fibrin sealant (Quixil) was injected into the fistula tract, and a rectal mucosal flap was used to close the internal opening. The fistula healed in few weeks, and the patient is symptom free after 1 year of follow-up.

Surgical intervention for anorectal fistula

BACKGROUND

Surgery for anorectal fistula may result in recurrence, or impairment of continence. The ideal treatment for anorectal fistulae should be associated with low recurrence rates, minimal incontinence and good quality of life.

OBJECTIVES

To assess the efficacy and morbidity of operative procedures for chronic anal fistula, primary outcomes being recurrence and incontinence.

SEARCH STRATEGY

The following databases were searched: EMBASE (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); Medline (Webspirs 5.1, Silver Platter version 2.0, 1950-2009); The Cochrane Central Register of Controlled Trials (2009 issue 4)and the IndMed ( Indian Medline, www.indmed.nic.in) database. We restricted our search to the English literature. The Indian Journal of Surgery was electronically searched (issues between 2003 and vol 71, Oct 2009). We also searched all primary trial registers (Indian, Australian, Chinese, WHO, ISRCTN and American).

SELECTION CRITERIA

Randomised controlled trials comparing operative procedures for anorectal fistulae were considered. Non randomised trials and cohort studies were examined where data on recurrence and function were available.

DATA COLLECTION AND ANALYSIS

Two reviewers (TJ and BP) independently selected the trials for inclusion in the review. Disagreements were solved by discussion. Where disagreement persisted and published results made data extraction difficult, we obtained clarification from the authors. REVMAN 5 was used for statistical analysis. Quality of the trials were assessed and allowances made for subgroup analysis and prevention of publication bias, using funnel plots if needed.

MAIN RESULTS

Ten randomised controlled trials were available for analysis. The quality of included studies was adequate, though in some trials the numbers were small and they were inadequately powered for equivalence or to detect significant differences. Comparisons were made between various modalities of treatments. There were no significant difference in recurrence rates or incontinence rates in any of the studied comparisons except in the case of advancement flaps. There were more recurrences in the glue plus flap group, a significant difference that favoured the flap only technique. It was also noted that Fibrin glue and advancement flap procedures report low incontinence rates.In the review of literature of non-randomised trials, most trials on fibrin glue indicate good healing in simple fistulae with low incontinence rates.

AUTHORS' CONCLUSIONS

There are very few randomized controlled trials comparing the various modalities of surgery for fistula in ano. While post operative pain, time to healing and discharge from hospital affect quality of life, recurrence and incontinence are the most important. As it turns out, there seems to be no major difference between the various techniques used as far as recurrence rates are concerned.The use of Fibrin glue and advancement flaps are associated with low incontinence rates.There is a crying need for well powered, well conducted randomised controlled trials comparing various modes of treatment of fistula in ano. Newer operations like the anal fistula plug and the LIFT procedure need to be evaluated by randomised clinical trials.

Perianal fistulae in Crohn's Disease: current and future approaches to treatment

: affecting sphincter integrity and continence. Traditional surgical and medical approaches are not without their limitations and may result in either comorbidity, such as fecal incontinence, or incomplete healing of the fistulae. Over the last 2 decades these limitations have led to a paradigm shift toward the use of biomaterials, and more recently cell-based therapies, which have met with variable degrees of success. This review discusses the traditional and current methods of treatment, as well as emerging and possible alternative approaches that may improve fistula healing.

The healing effects of tissue glues and healing agent locally applied on esophageal anastomoses

OBJECTIVE

This study aimed to investigate the effects of cyanoacrylate (C), fibrin glue (FG), and natrium hyaluronate (NH) on the healing of esophageal anastomosis (EA).

METHODS

Twenty-four rabbits were divided equally into 4 groups: primary anastomosis (PA), C, FG, and NH. A 1-cm-length of the cervical esophagus was resected through a cervical incision and then anastomosis was performed. C, FG, and NH were instilled into anastomosis lines in the respective groups. The animals were fed orally on postoperative day 7 on the condition that there was no esophageal leakage. The rabbits were sacrificed 8 weeks later to evaluate bursting pressure (BP), tissue hydroxyproline (HP) levels and wound healing scores (WHSs) in the anastomosis lines.

RESULTS

BP was significantly higher in the C group than in the PA, FG, and NH groups, and HP was significantly lower than in the other groups. WHSs in the PA and NH groups were lower than in the C and FG groups.

CONCLUSIONS

C and NH appear to be beneficial in EA healing with respect to increased BP and decreased HP when they are used simultaneously with PA prophylactically to prevent esophageal leakages and stricture.

Anorectal Crohn's disease: surgical and medical management

In some patients with Crohn's disease the anorectal complications are the major cause of symptoms and morbidity. Anorectal Crohn's disease may be present in patients with intestinal Crohn's disease, may be the initial manifestation of the disease, or rarely occurs without involvement of Crohn's disease elsewhere in the intestinal tract. The pathogenesis of these anorectal complications remains to be clarified. The anorectal examination is very important in the assessment of patients with suspected or documented inflammatory bowel disease. Meticulous physical examination, examination under anaesthesia and radiological imaging modalities may be utilised to specifically identify the location of abscesses and fistulae. Treatment strategy should be directed toward symptomatic relief; the most important symptom is pain. In most patients this pain will be attributable to an incompletely drained rectal abscess. Simple incision and drainage procedures are often all that is required as initial treatment of anorectal abscesses. Treatment of the anorectal fistulae that occur secondary to Crohn's disease requires combined medical and surgical therapy. Drug therapy is more often initiated for Crohn's disease that involves other areas of the gastrointestinal tract. The anorectal manifestations often respond to these same medications. Lay-open procedures (fistulotomies) are often all that is required surgically for simple (low) anorectal fistulae. High (complex) fistulae that involve large portions of the anorectal muscular ring are more difficult to treat. Patients with these fistulae must be treated on an individual basis, usually local surgical therapy combined with a medical regimen. Many surgical procedures are performed and many classes of medications are utilised on patients with these complex anorectal fistulae. Choosing the appropriate surgical and medical interventions is often quite difficult. Although sulfasalazine, mesalazine and corticosteroids have no lasting or maintenance value for fistulae, the immunosuppressive agents mercaptopurine, azathioprine and cyclosporin, the antibacterial metronidazole and the anti-tumour necrosis factor-alpha monoclonal antibody infliximab have varying degrees of effect. The goal of the combined regimen is to cure the fistula, or at least make it minimally symptomatic, without altering the patient's continence.

A anorectal fistula treatment with acellular extracellular matrix: A new technique

AIM: To investigate a new technique of the anorectal fistula treatment with acellular extracellular matrix (AEM).

METHODS: Thirty patients with anorectal fistula were treated with AEM. All fistula tracts and primary openings were identified using conventional fistula probe. All tracts were curetted with curet and irrigated with hydrogen peroxide and metronidazole. The AEM was pulled into the fistula tract from secondary to primary opening. The material was secured at the level of the primary opening. The excess AEM was trimmed at skin level at the secondary opening.

RESULTS: All of the 30 patients had successful closure of their fistula after a 7-14 d follow-up. The healing rate of anal fistula in treatment group was 100%. The ache time, healing time and anal deformation of treatment group were obviously superior to traditional surgical methods.

CONCLUSION: Using AEM anal fistula plug in treatment that causes the anorectal fistula is safe and successful in 100% of patients. It can reduce pain, shorten disease course and protect anal function.

Fistula-in-ano: advances in treatment

BACKGROUND

Several techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. Technology has evolved over the past 2 decades that may enable surgeons to deal with this troublesome issue with greater success. This review summarizes the history of fistula-in-ano management, the current techniques available, and describes new technologies.

METHODS

Medline searches were performed using the PubMed, Ovid, Embase, Cochrane, and Google Scholar databases to identify articles reporting on fistula-in-ano management using surgery alone, fibrin glues, and fistula plugs. Forty-one articles reporting on the history of fistula-in-ano management and the use of new technologies were included.

RESULTS

Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues and the anal fistula plugs offer an alternative approach, with initial studies reporting good success rates.

CONCLUSIONS

New technologies provide promising alternatives to traditional methods of management. There is, however, a real need for high-quality randomized control trials.

Recovery rates and functional results after repair for rectovaginal fistula in Crohn's disease: a comparison of different techniques

BACKGROUND AND OBJECTIVES

Rectovaginal fistulas (RVF) in Crohn's disease continue to be a challenging problem. Several operations are often necessary to attain definitive healing of the disease process. There are no guidelines concerning optimal therapeutic approaches. Endoanal mobilization techniques such as the advancement flap technique were considered the therapy of choice for many years, but are now regarded ever more critically. We have implemented several less aggressive closure techniques that take account of the anatomy and morphology of the anorectum. The long-term results are presented in this paper.

MATERIALS AND METHODS

The method used was observational analysis with a standard protocol of all patients with RVF and Crohn's disease treated surgically at a single institution.

RESULTS/FINDINGS

Between January 1985 and December 2002, we treated 72 patients with low rectovaginal fistulas. The operations comprised 56 procedures performed in 37 women presenting with RVF. The patients' median age was 34.6 +/- 10 years; the follow-up period was 7.15 years (10 months-18 years). Several techniques were performed: transverse transperineal repair (n = 20), endoanal direct closure multilayer without flap (n = 15), anocutaneous flap (n = 14), and advancement mucosal or full-thickness flap (n = 7). Diverting ileostomies were created in 28 patients (76%). Recovery was achieved with the initial repair in 19 patients (51.4%). An additional 12 patients underwent repeat procedures (2-5), with an overall success rate of 27:37 (73%). The rate of recurrence was 30% during a follow-up period of 7.1 years. The rate of proctectomy was 13.5%. The success rates for each of the techniques in the above group were 70, 73, 86, and 29%, respectively. They were significantly higher with the direct closure and anocutaneous flap technique than with the advancement flap technique. However, the transperineal repair led to decreased postoperative resting pressures. In the advancement flap technique, the resting and squeezing pressure decreased significantly. The risk of developing a suture line dehiscence leading to a persisting fistula was higher in the advancement flap procedure with 43%.

INTERPRETATION/CONCLUSION

Techniques with a low degree of tissue mobilization such as the direct closure and anocutaneous flap show higher success rates without significant postoperative changes in continence and manometric outcome. Impaired continence was observed only in the advancement flap group, resulting in significant changes in manometric values and recovery rates. The authors prefer to apply the direct multilayer closure technique without flap.

Evaluation of the use of BioGlue in the treatment of high anal fistulas: preliminary results of a pilot study

PURPOSE

Treatment of anal fistulas by use of adhesives is an attractive method because of its simplicity and it can be performed on an ambulatory basis. Furthermore, if the treatment is unsuccessful, adhesive use does not subsequently prevent the surgeon from utilizing alternative surgical techniques and/or products. BioGlue Surgical Adhesive is a two-component surgical adhesive composed of bovine serum albumin and glutaraldehyde. We evaluated the usefulness of BioGlue for the treatment of high transsphincter anal fistulas.

METHODS

Patients diagnosed with high transsphincter anal fistulas of cryptoglandular origin, whether relapsed or not, were included in this study. A seton was placed before the injection of BioGlue into the fistula track of high transsphincter anal fistulas in patients with secondary tracts and/or purulent collections. Clinical charts, operative reports, and endoanal echography results obtained for each patient were reviewed.

RESULTS

Fourteen patients (13 males; mean age, 39.9 (range, 24-66) years) with high transsphincter anal fistulas of cryptoglandular origin were recruited into the study. The average time of symptom evolution was 35.6 (range, 2-96) months. Ten of 14 cases were for relapsed fistulas. Six patients required the placement of a seton 37 (range, 32-42) days before the BioGlue injection. Patients were followed for a mean length of 13.92 (range, 3-21) months, and the fistula healed completely in only seven patients (50 percent).

CONCLUSIONS

These preliminary results demonstrate that BioGlue may be useful for treating patients with high transsphincter anal fistulas. Further prospective long-term studies are needed.

Laparoscopic bilateral hernia repair using fibrin sealant: technical report of two cases

Minimally invasive surgery is widely used in hernia repair given its advantages such as minimal disturbance to the surrounding tissues, shorter hospital stay, and promising long-term results. Efforts are still being made to make this minimally invasive procedure even more minimal. New tissue adhesives avoid the use of foreign materials and the postoperative pain that might be attributed to staples. We present the first two cases of bilateral inguinal hernia repair performed with a totally extraperitoneal procedure using fibrin sealant instead of staples for the fixation of the mesh.

Fístula anal de origen criptoglandular. Opciones terapéuticas

Anal fistula is a frequent condition. The most commonly accepted origin is infectious. The most widely used classification is based on cryptoglandular theory and on the position of the fistulous tract in relation to the anal sphincter. Physical examination will help to identify the type of fistula and allow its treatment to be planned. The most widely used complementary tests are endoanal ultrasound and magnetic resonance imaging. We review the various therapeutic options and their results, especially fistulotomy, endorectal advancement flap, use of sedal, anodermal advancement flap, sphincterorrhaphy with sphincter repair, and fibrin glue.

Fibrin glue in the treatment of pilonidal sinus: results of a pilot study

INTRODUCTION

Pilonidal sinus is a common condition of uncertain etiology. There is no agreed best surgical treatment. Treatment of fistula-in-ano has been described with some success with fibrin tissue glue. The use of fibrin glue is investigated in this pilot study.

METHODS

Six patients with chronic pilonidal sinus were treated with injection of fibrin tissue glue after curettage of the pits.

RESULTS

There were no complications. Postoperative discomfort was minimal and early return to normal activities was possible. There was no recurrence of disease in five of six patients at one year.

CONCLUSIONS

Fibrin tissue glue may be a possible novel treatment for pilonidal disease.

Pilot study: fibrin sealant in anal fistula model

PURPOSE

The aim of this study was to investigate the failure of fibrin sealant treatment for fistula-in-ano in an experimental porcine model and to determine histologic changes associated with the sealant and setons.

METHODS

Three surgically created fistulas were treated by seton drainage in each of eight male pigs. After 26 days, magnetic resonance imaging was performed and setons were removed. Two pigs were killed as controls for stereologic histologic fistula track assessment. In six, fistulas were curetted, and in four the fistulas were treated with fibrin sealant. In these four sealant and two seton pigs, magnetic resonance imaging was repeated a median of 47.5 days after fistula formation. The pigs were killed and stereologic histologic fistula track examination was performed to determine granulation tissue and fistula lumen volumes. These values were compared among control, seton, and sealant groups over time, and related to fistula volumes derived from magnetic resonance imaging.

RESULTS

Sealant was not visible microscopically within tracks, although some sections revealed a foreign body-type reaction. On stereologic assessment, granulation tissue volumes were smaller in sealant and seton groups than in controls (median, 88 vs. 187 vs. 453 mm3, respectively; P = 0.002) and decreased over time (median, 408 and 152 mm3 (Day 42) vs. 88 and 75 (Day 53), respectively; P = 0.002). Fistula lumen (P < 0.001), and granulation tissue combined with fistula lumen volumes (P = 0.002) were similarly smaller. Magnetic resonance imaging of fistula intensity was less in the sealant group than in the seton group and controls (mean, 777 vs. 978 vs. 1214 units/mm2, P = 0.003). Magnetic resonance imaging fistula volumes were least in sealant and seton groups vs. controls (P = 0.024), decreasing significantly in the sealant group over time (P = 0.018). No direct relationship was found between imaging and histologic volumes.

CONCLUSIONS

In an experimental porcine model of anal fistula, granulation tissue was still present, albeit diminished, following track curettage combined with seton or sealant therapy, and was minimal in the sealant group, confirming some benefit from this procedure. Eradication of all longstanding granulation tissue may ensure complete success of fibrin sealant therapy.

Experimental model of fistula-in-ano

PURPOSE

This study was designed to create and evaluate an experimental porcine model of fistula-in-ano.

METHODS

Initial cadaveric dissection enabled refinement of the technique for fistula formation and histoanatomical study of the porcine anal canal. Subsequently, three surgically created fistulas were treated by seton drainage in each of eight male pigs (weight, 38-41 kg). After 26 days, magnetic resonance imaging at 1.5 Tesla was performed and setons removed under general anesthesia, enabling clinical and microbiologic track assessment. Two pigs were killed for histologic fistula track assessment.

RESULTS

Histoanatomical assessment noted a rudimentary internal anal sphincter, together with structures resembling anal glands. Artificial fistulas persisted during seton drainage and were more often associated with fecal than skin-derived organisms compared with both perineal and anal canal swabs (P = 0.002). All six fistulas assessed histologically had a lumen, and abundant surrounding granulation tissue similar to that seen in human fistula-in-ano. Epithelialization was not evident in any track. Fistulas were visualized as high signal tracks using magnetic resonance imaging.

CONCLUSIONS

Porcine anal anatomy resembles that of humans, and an experimental model proved suitable when assessed by magnetic resonance imaging, microbiology, and histologically, which demonstrated abundant granulation tissue. This model could be further used to investigate fistula treatments.

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.

Fibrin glue treatment of complex anal fistulas has low success rate

PURPOSE

Fibrin glue has been used to treat anal fistulas in an attempt to avoid more radical surgical intervention. Reported success rates vary widely. The purpose of this study was to review the use of fibrin glue in the management of complex anal fistulas at a tertiary referral center.

METHODS

This study was designed as a retrospective review of all patients treated with fibrin glue injection for complex anal fistulas in the Section of Colon and Rectal Surgery, Washington University School of Medicine/Barnes-Jewish Hospital. Demographics, previous treatment, operative information, and early follow-up were obtained from the patients' medical records. Phone interviews were conducted to determine successful healing or recurrence of fistulas requiring further treatment. Statistical analysis was by Fisher's exact test. The institutional review board approved the study.

RESULTS

A total of 42 patients (19 males; median age, 44 (range, 20-76) years) were treated between 1999 and 2002. Three patients were lost to follow-up and were excluded from the study. Etiology of fistulas were cryptoglandular (n = 22), Crohn's disease (n = 13), or coloanal and ileal pouch-anal anastomotic (n = 4). Fistulas were classified as deep transsphincteric (n = 33), superficial transsphincteric (n = 1), supralevator (n = 2), or rectovaginal (n = 3). Initially, most patients had "closure" of the fistula but recrudescence was common. Durable healing was only achieved in 31 percent (12/39). Healing rates by etiology were cryptoglandular 23 percent (5/22), Crohn's disease 31 percent (4/13), and ileal pouch-anal anastomotic 75 percent (3/4; P = 0.14). Success rates by classification were deep transsphincteric 33 percent (11/33), superficial transsphincteric 0 percent (0/1), supralevator 0 percent (0/2), and rectovaginal 33 percent (1/3; P = 1). The success rate for patients with no previous treatment was 38 percent (8/21) vs. 22 percent (4/18) in those whose fistulas had been previously treated ( P = 0.32). Eight patients underwent a second fibrin glue treatment and only one of them healed (12.5 percent). Median follow-up for successfully healed fistula was 26 months.

CONCLUSIONS

Fibrin glue treatment for complex anal fistulas has a low success rate and most recrudescences occurred within three months. However, given the low morbidity and relative simplicity of the procedure, fibrin glue should still be considered as a first-line treatment for patients with complex anal fistulas.

Closure of Proximal Colorectal Fistulas Using Fibrin Sealant

Fibrin glue has been used in upper gastrointestinal and perianal fistula disease, but its success in proximal colorectal pathology has not been widely documented. This report describes the use of endoscopically injected fibrin glue as a successful adjunct to traditional methods in accelerating the closure of colorectal fistulas. A retrospective review was performed on cases of colon and rectal fistulas treated with fibrin glue using an endoscopic technique of injection. Fistulas were injected via a flexible fiberoptic endoscope with fluoroscopic guidance (three) or directly with a rigid proctoscope (one). Fibrin glue was mixed directly from cryoprecipitate, thrombin, and calcium (one) or using a Tisseel® kit (three) (Baxter, Deerfield, IL). Four patients were identified and included: two J-pouch fistulas, a colocutaneous fistula, and a complex rectocutaneous fistula. The median duration of fistula was 33 days (range 4–365 days). Total parenteral nutrition and bowel rest were used in two patients and three required drainage of an abscess. All fistulas were obliterated and patients required a mean of one application of fibrin glue (range one to two). The mean time to resuming a regular diet postinjection was 2 days (range 1–5). No complications were identified. Fistula resolution was documented in all cases with a contrast enema and no patient has had a fistula recurrence at a median follow-up of 12 months (range 6–65). This preliminary series demonstrates that fibrin glue can be used to obliterate proximal rectal, colonic, and pouch fistulas. Endoscopy and fluoroscopy may aid in administering the fibrin glue. This adjunctive technique may shorten the time to fistula closure and may allow some patients to avoid further surgery.

The outcome of surgery for complex anal fistula

OBJECTIVE: The aim of this study was to examine the results of surgery for complex anal fistulas treated by a variety of techniques, in terms of fistula healing, recurrent anal sepsis and effect of surgery on anal continence. PATIENTS AND METHODS: This study included 63 patients with complex fistulas treated between November 1995 and September 1999. A variety of techniques were employed, including short-term loose seton drain (12), long-term loose seton drain (11), cutting seton (17), and rectal advancement flap (19). Outcome was assessed at clinic review and continence was further assessed by detailed questionnaire sent to the patients sometime after surgery. RESULTS: Healing occurred in 9 (75%) patients treated with a short-term, loose drainage seton; 16 (94%) patients treated with a cutting seton and 17 (89%) patients in the rectal advancement flap group. Incontinence reported at clinic review seemed to be more frequent in the advancement flap group. However, a detailed continence questionnaire revealed that 50% of patients reported episodes of incontinence to flatus or liquid after all techniques, which had not been detected at routine clinical review. Incontinence to solids was only reported by two of the patients who had been treated with a cutting seton. CONCLUSIONS: Complex fistulas may be successfully treated by a variety of techniques. Disturbed anal continence following surgery is common and worse than clinic assessment would suggest.

Fibrin glue for all anal fistulas

The aim of this study was to determine if a new sphincter muscle-sparing technique that uses fibrin glue was effective in closing all types of anal fistulas. All patients with anal fistulas who were seen by a single surgeon over a 2-year period were treated with fibrin glue. Six to 8 weeks after a seton was placed in the fistula tract, either autologous fibrin glue or commercially available fibrin sealant was used to close the fistula tract. Twenty patients were treated with a mean follow-up of 10 months. Etiology of the anal fistulas was as follows: cryptoglandular in 13, Crohn's disease in four, and miscellaneous in three. Fibrin glue closure of the anal fistula was successful initially in 15 patients (75%) and was successful after a second treatment in two additional patients, for an overall fibrin glue fistula closure rate of 85% (17 of 20). Functional results have remained excellent with no patient reporting any change in continence after treatment. Fibrin glue is simple and effective treatment for all anal fistulas with excellent functional results.