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

Collagen treatment of complex anorectal fistula: 3 years follow-up

Fistula in ano is a common anorectal disease in adults. Currently, surgery remains the definitive therapeutic approach, but in some cases, it can lead to serious complications as faecal or gas incontinence. Therefore, sphincter sparing treatments should be considered for complex fistulas. One of the sphincteric preserving treatment is the filling with a dermal extract commonly called "collagen glue" as Salvecoll-E^® gel. This is a multicentric, prospective, observational study on the use of Salvecoll-E^® gel in treatment of complex anal fistulas. We treated 70 patients from May 2016 to May 2017. In the first phase, we debrided the fistula tract using a loose seton kept for 4-6 weeks. In the second phase, the seton was removed and the fistula tract was filled with Salvecoll-E^® gel. In this article, we report results at 36 months of follow-up. Fifty patients (71.4%) had completely healed fistula within 36 months of follow-up. Twenty-eight patients (28.2%) had recurrences. Among these failures, 65% were within 6 months. All low transphincteric fistulas healed. Recurrences occurred only in median and high transphincteric fistulas. No patient had a worsening of continence status measured with Cleveland Clinic Florida Incontinence Severity score. Salvecoll-E^® gel is a recent finding among sphincter-sparing treatments. In this study, we demonstrate that it is a safe option in the treatment of complex fistulas. Final results are satisfactory and in line with the best results published in literature among mini-invasive treatments.

The Value of Transrectal Ultrasound in the Preoperative Diagnosis of Complex Anal Fistula (CAF): Based on a Retrospective Cohort Study

Objective

A case-control study was employed to retrospectively analyze the value of transrectal ultrasound in the preoperative diagnosis of complex anal fistula (CAF).

Methods

The clinical data of 128 patients with CAF treated in our hospital from March 2019 to June 2021 were analyzed retrospectively. All patients were examined by transrectal ultrasound and MRI with Hitachi HI Vision Ascendus ultrasound diagnostic apparatus and MRI. The general data of the patients (age, sex, course of disease, complications, and previous operation history) and ultrasonic image characteristics were recorded. The consistency of internal orifice, head, branch/abscess, and abscess detected by ultrasound, MRI, and ultrasound combined with MRI were compared, and the sensitivity, accuracy, and specificity of ultrasound, MRI, and the combination of ultrasound and MRI (ultrasound+MRI) in the diagnosis of different Parks classification of anal fistula (AF) were compared.

Results

The ultrasound images of the rectal probe in typical cases were compared with the MRI images. The characteristics of the ultrasound images were as follows: the outer orifice of AF was a thin strip of mixed echo or low echo leading to the skin side, and the inner orifice showed local dilated low echo, mixed echo, or interruption of mucosal continuity. The following are the MRI image features: abnormal long bar signal shadow from the dorsal side of the end of the coccyx to the S5 plane, low signal on T1WI, high signal on T2WI, blurred boundary, uneven signal, bifurcation in the lower end of the tail for "Y" shape, one branch opening at the body surface at about 6 o'clock, the other walking horizontally, passing through the levator ani muscle to the right posterior position of the rectum at about 6:00 o'clock, and penetrating the inner mouth of the rectum at 6 o'clock. The detection of internal orifice, head, branch/abscess, and abscess were compared by three examination methods. There was significant difference in the detection rate of internal orifice and branch/purulent cavity among the three methods (P < 0.05). The detection rates of internal mouth and branch/abscess cavity by ultrasound and MRI (94.77% and 94.94%) were higher than those by single ultrasound (75.16% and 79.78%) and MRI (81.05% and 83.15%) (P < 0.05). There was no significant difference in the detection rate of ultrasound, MRI internal orifice, and branch/purulent cavity (P > 0.05). There was no significant difference in the detection rate of supervisor and abscess among the three methods (P > 0.05). The results of operation included transsphincter type (n = 53), intersphincter type (n = 45), and superior sphincter type (n = 30). Analysis of transsphincter type AF detected by three methods: 42 cases of transsphincter type AF and 86 cases of nonsphincter type AF were detected by ultrasound, 36 cases of transsphincter type AF and 92 cases of nontranssphincter type AF were detected by MRI, 57 cases of transsphincter type AF and 71 cases of nonsphincter type AF were detected by ultrasound and MRI. The comparison of the efficacy of the three methods in the diagnosis of transsphincter AF and the sensitivity of the three methods in the diagnosis of transsphincter AF showed significant difference (P < 0.05). The sensitivity of ultrasound and MRI in the diagnosis of transsphincter AF (96.23%) was higher than those of single ultrasound (67.92%) and MRI (64.15%) (P < 0.05). There was no significant difference in the accuracy and specificity of the three methods in the diagnosis of transsphincter AF (P > 0.05). There were 41 cases of intersphincter type AF and 87 cases of nonsphincter type AF detected by ultrasound, 38 cases of intersphincter type AF and 90 cases of nonsphincter intersphincter type AF detected by MRI, and 45 cases of intersphincter type AF and 83 cases of nonsphincter intersphincter type AF detected by ultrasound and MRI. The sensitivity and accuracy of the three methods in the diagnosis of intersphincter AF were statistically significant (P < 0.05). The sensitivity and accuracy (100.00% and 100.00%) of ultrasound and MRI in the diagnosis of intersphincter AF were higher than those of single ultrasound (66.67% and 79.69%) and MRI (71.11% and 85.16%) (P < 0.05). There was no significant difference in the specificity of the three methods in the diagnosis of intersphincter AF (P > 0.05). The results of three methods were compared, including 24 cases of superior sphincter type AF and 89 cases of nonsuperior sphincter type AF, 21 cases of superior sphincter type AF, and 107 cases of nonsuperior sphincter type AF detected by MRI and 93 cases of superior sphincter type AF and 128cases of nonsuperior sphincter type AF detected by ultrasound and MRI. There was no significant difference in the sensitivity, accuracy, and specificity of the three methods in the diagnosis of superior sphincter AF (P > 0.05).

Conclusion

The sphincter, anorectal, and surrounding tissues were clearly demonstrated by transrectal ultrasound. The internal orifice, head, branch/abscess, abscess, and the relationship between abscess and sphincter in the diagnosis of CAF were in good agreement with the surgical results. Ultrasound+MRI can take into account the advantages of ultrasound and MRI, make up for each other, and improve the detection rate of internal orifice and branch/abscess. It can improve the sensitivity of diagnosis of transsphincter AF and the sensitivity and accuracy of intersphincter AF, which can provide intuitive and valuable imaging information for surgical intervention.

Treatments for the amelioration of persistent factors in complex anal fistula

Anal fistulae are abnormal hollow connections between the wall of the anal canal and the perianal skin around the anus that have remained a burden on the medical sector for centuries. The complexity of this disease is attributed to a number of factors such as the degree of associated sphincter muscle, concomitant illnesses, existence of multiple fistulous tracts and the number of previous interventions. Persistence of a complex anal fistula can cause a decline in patient's physical quality of life as well as impact on the psychological status of patients who often suffer from anxiety and depression. Surgical intervention remains the gold standard for treatment, however; the risk of incontinence and high recurrence potential has led to interest into developing alternative treatment approaches such as the use of biologics, bioactives and biomaterials. One potential reason for these varied outcomes could be the multifactorial interplay between genetic, immune-related, environmental, and microbial persistence factors on tissue regeneration. Recent observations have proposed that adverse inflammatory mediators may contribute more than microbial factors. The moderate to high success rates of biotechnological advances (mesenchymal stem cells and biomaterial scaffolds) show promise as therapies for the amelioration of adverse persistent factors while facilitating a means to closing the fistula tract. The purpose of this review is to outline recent advances in biologics and combination therapies to treat persistent factors associated with complex anal fistula.

Efficacy of Permacol injection for perianal fistulas in a tertiary referral population: poor outcome in patients with complex fistulas

AIM

Injection of Permacol collagen paste can be used as a sphincter-sparing treatment for perianal fistulas. In a tertiary referral population we aimed to evaluate the efficacy of Permacol injection and the clinical and fistula-related factors associated with recurrence.

METHOD

This was a retrospective analysis of consecutive patients with perianal fistulas treated with Permacol injection at a specialist centre between June 2015 and April 2019. Endoanal ultrasonography was systematically reanalysed, blinded to treatment outcome. Rectovaginal, anovaginal and Crohn's disease fistulas were excluded. Healed fistulas were defined as absent anal symptoms and a closed external opening on physical examination at a minimum follow-up of 6 months. Regression analyses were performed to identify factors associated with unhealed fistulas.

RESULTS

A total of 90 patients (51 men; median age 45 years) were analysed. Seventy-two (80.0%) patients had complex perianal fistulas (greater than one-third sphincter involvement or multiple tracts). After a single Permacol injection, fistulas were healed in 20 (22.2%) patients at 3 months follow-up and in 18 (20.0%) patients at a median follow-up of 30 months (interquartile range 17-37). Eight (11.1%) patients with unhealed fistulas had significant improvement in their symptoms. Complex fistulas were significantly associated with unhealed status [OR 3.53 (95% CI 1.12-11.09); p = 0.031]. Twenty patients underwent subsequent Permacol injections, which were successful in six (30.0%) patients after one (n = 3) or two (n = 3) additional injections.

CONCLUSION

This largest study to date in patients with mainly complex perianal fistulas, demonstrated that the efficacy of a single Permacol injection was only 20%. Complex fistulas were associated with a poor outcome.

A New, Conservative Treatment for Perianal Fistula that May Halve the Need for Surgical Intervention: Case Series

PURPOSE

In the last two decades, many sphincter preservation techniques have been proposed for the treatment of anal fistula. Since 2011, our surgical team has treated fistulas by sealing them with platelet-rich fibrin (PRF). This is performed actually as an outpatient process, without anaesthesia.

METHODS

Patients were treated with PRF sealant, during the period June 2012-March 2017. The fibrin preparation is applied in the fistulous tract, with no need for any type of anaesthesia, and so the patient can go home immediately afterwards, without further observation.

RESULTS

After an average follow-up of 26.49 months, the perianal fistula had healed completely in 52.86% of the patients (n = 37), who each received an average of 1.92 sealant operations. In another 10 cases, the sealing was initially successful, but a relapse occurred during the follow-up period.

CONCLUSION

The outpatient treatment of perianal fistula with PRF is totally harmless, is very low cost and achieves very acceptable results. In our opinion, therefore, this could be considered an appropriate initial treatment for perianal fistula, with surgical treatment being reserved if this approach is unsuccessful, thereby avoiding many complications and producing significant economic savings for the health system.

FISSIT (Fistula Surgery in Italy) study: A retrospective survey on the surgical management of anal fistulas in Italy over the last 15 years

BACKGROUND

Surgical treatment of anal fistulas is still a challenge. The aims of this study were to evaluate the adoption and healing rates for the different surgical techniques used in Italy over the past 15 years.

METHODS

This was a multicenter retrospective observational study of patients affected by simple and complex anal fistulas of cryptoglandular origin who were surgically treated in the period 2003-2017. Surgical techniques were grouped as sphincter-cutting or sphincter-sparing and as technology-assisted or techno-free. All patients included in the study were followed for at least 12 months.

RESULTS

A total of 9,536 patients (5,520 simple; 4,016 complex fistulas) entered the study. For simple fistulas, fistulotomy was the most frequently used procedure, although its adoption significantly decreased over the years (P < .0005), with an increase in sphincter-sparing approaches; the overall healing rate in simple fistulas was 81.1%, with a significant difference between sphincter-cutting (91.9%) and sphincter-sparing (65.1%) techniques (P = .001). For complex fistulas, the adoption of sphincter-cutting approaches decreased, while sphincter-sparing techniques were mildly preferred (P < .0005). Moreover, there was a significant trend toward the use of technology-assisted procedures. The overall healing rate for complex fistulas was 69.0%, with a measurable difference between sphincter-cutting (81.1%) and sphincter-sparing (61.4%; P = .001) techniques and between techno-free and technology-assisted techniques (72.5% and 55.0%, respectively; P = .001).

CONCLUSION

Surgical treatment of anal fistulas has changed, with a trend toward the use of sphincter-sparing techniques. The overall cure rate has remained stable, even if the most innovative procedures have achieved a lower success rate.

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.

A bioactive injectable bulking material; a potential therapeutic approach for stress urinary incontinence

Stress urinary incontinence (SUI) is a life changing condition, affecting 20 million women worldwide. In this study, we developed a bioactive, injectable bulking agent that consists of Permacol™ (Medtronic, Switzerland) and recombinant insulin like growth factor-1 conjugated fibrin micro-beads (fib_rIGF-1) for its bulk stability and capacity to induce muscle regeneration. Therefore, Permacol™ formulations were injected in the submucosal space of rabbit bladders. The ability of a bulking material to form a stable and muscle-inducing bulk represents for us a promising therapeutic approach to achieve a long-lasting treatment for SUI. The fib_rIGF-1 showed no adverse effect on human smooth muscle cell metabolic activity and viability in vitro based on AlamarBlue assays and Live/Dead staining. Three months after injection of fib_rIGF-1 together with Permacol™ into the rabbit bladder wall, we observed a smooth muscle tissue like formation within the injected materials. Positive staining for alpha smooth muscle actin, calponin, and caldesmon demonstrated a contractile phenotype of the newly formed smooth muscle tissue. Moreover, the fib_rIGF-1 treated group also improved the neovascularization at the injection site, confirmed by CD31 positive staining compared to bulks made of Permacol^TM only. The results of this study encourage us to further develop this injectable, bioactive bulking material towards a future therapeutic approach for a minimal invasive and long-lasting treatment of SUI.

Comparison of porcine collagen paste injection and rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a 2-year follow-up study

BACKGROUND

Rectal advancement flap is the standard surgical treatment for complex cryptoglandular anal fistulas, while Permacol™ collagen paste is considered an innovative treatment option for anorectal fistulas. This study aimed to compare the clinical outcomes of patients with complex cryptoglandular fistulas treated by endorectal advancement flap versus Permacol™ paste.

METHODS

This study was a retrospective analysis of patients with complex cryptoglandular anal fistulas. Thirty-one patients were treated with the rectal advancement flap (RAF group), while 21 were treated with Permacol™ paste injection (PP group). In PP group, the approach consisted of loose seton positioning followed several weeks later by closure internal opening with a resorbable sutures associated with paste injection into the fistula track. Clinical outcomes were assessed in terms of healing rate, faecal continence and patient satisfaction.

RESULTS

Seton drainage was done in all patients in both groups for a median duration of 8 weeks (range 4-18 weeks) before the final surgery (p = 0.719). No patient had faecal incontinence (CGS ≥ 5) preoperatively. Five patients (16%) in the RAF group and one (5%) in the PP group experienced faecal incontinence postoperatively. The 2-year disease-free survival was 65% in the RAF group and 52% in the PP group (p = 0.659). The median satisfaction scores were 5 (range 1-10) in the RAF group and 7 (range 2-10) in the PP group (p = 0.299).

CONCLUSION

The RAF appeared superior to PP in terms of fistula healing, although this result was not statistically significant. On the contrary, PP has a potential advantage in terms of continence disorders. Permacol™ paste can be considered as the initial treatment option for complex cryptoglandular anal fistulas in patients with faecal continence disorders.

Permacol Collagen Paste Injection for Treatment of Complex Cryptoglandular Anal Fistulas: An Observational Cohort Study With a 2-Year Follow-up

BACKGROUND

Permacol paste injection is a novel treatment approach for complex cryptoglandular anal fistulas. This study was performed to evaluate the long-term clinical outcomes of treatment with Permacol paste for complex cryptoglandular fistulas.

METHODS

Patients with primary or recurrent complex cryptoglandular anal fistulas treated with Permacol paste from 2014 to 2016 were retrospectively analyzed.

RESULTS

A total of 46 patients (median age, 41.3 years; 21 female) underwent Permacol paste injection; 20 patients (43%) had previously undergone failed fistula surgery. The patients had experienced anal fistula-related symptoms for a median of 10 weeks (range, 3-50 weeks). All patients had a draining seton in situ for a median of 10 weeks (range, 4-46 weeks). The median follow-up time was 24 months (range, 1-25 months). At the 1-month follow-up, 2 patients had paste extrusion and 2 had anal abscesses. The mean preoperative Continence Grading Scale score was 1.10 ± 1.40, and that at 3 months postoperatively was 1.13 ± 1.39 ( P = .322). There was a significant difference in the preoperative and the 1- and 3-month postoperative pain scores ( P < .001). At the 24-month follow-up, the healing rate was 50% (n = 23). A total of 19 patients (41%) with a recurrent fistula after failed Permacol paste injection required additional operative procedures. The satisfaction rate at the 2-year follow-up was 65%.

CONCLUSION

Permacol paste injection is minimally invasive and technically easy to perform. It can be considered as a viable and reasonable option for the treatment of complex cryptoglandular anal fistulas in patients with fecal continence disorders.

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.

Micro-fragmented adipose tissue injection for the treatment of complex anal fistula: a pilot study accessing safety and feasibility

BACKGROUND

The aim of the present study was to evaluate the safety and efficacy of autologous, micro-fragmented and minimally manipulated adipose tissue injection associated closure of the internal opening in promoting healing of complex anal fistula.

METHODS

A pilot study was conducted on patients referred to our center with anal fistula, from April 2015-December 2016. Inclusion criteria were age over 16 years old and a diagnosis of complex anal fistula according to the American Gastroenterological Association classification The patients were divided into 2 groups; the "first time group" (Group I) in which micro-fragmented adipose tissue injection with closure of the internal opening was the first sphincter-saving procedure, and the "recurrent group" (Group II) consisting of patients who had failed prior sphincter-saving procedures. The procedure was carried out 4-6 weeks after seton placement. Follow-up visits were scheduled at 7 days, and 1, 3, 6 and 12 months after surgery. Fistula healing was defined as the closure of the internal and external openings without any discharge.

RESULTS

Out of 47 patients with complex transsphincteric anal fistula, 19 met the inclusion criteria and were selected to undergo the procedure. Twelve of these patients (Group I) had micro-fragmented adipose tissue injection as first-line treatment, and 7 (Group II) had failed previous sphincter-saving procedures. The mean operative time was 55 ± 6 min (range 50-70 min). The mean postoperative pain score measured with the visual analog pain scale was 2 ± 1.4 (range 0-4). No intraoperative difficulties related to the use of the kit were recorded. There were no cases of postoperative fever or abdominal sepsis related to the procedure and no post-treatment perianal bleeding or impaired anal continence. Only 3 cases of minor abdominal wall hematoma that did not require any treatment and 1 case of perianal abscess were observed. Patients were evaluated for a mean follow-up time of 9 ± 3.1 months (range 3-12 months). The overall healing rate was 73.7, 83.3% for Group I and 57.1% for Group II.

CONCLUSIONS

The injection of autologous, micro-fragmented and minimally manipulated adipose tissue associated with closure of the internal opening is a safe, feasible and reproducible procedure and may enhance complex anal fistula healing.