[Long-term follow-up of the treatment of high anal fistulas using fibrin glue]

The role of loose seton in the management of anal fistula: a multicenter study of 200 patients

BACKGROUND

Perianal abscesses and fistulae-in-ano are a common anorectal complaint causing significant distress to patients, and present a considerable treatment challenge. Principal of treatment is achieving closure of the fistula while maintaining continence. There are numerous treatment approaches with large debate about which method is "ideal." Our aim was to assess the tolerance and efficacy of loose seton placement in the treatment for fistula-in-ano.

METHODS

We performed a retrospective multicenter review of the management of anal fistulae with loose seton placement over a three-year period. All patients underwent a standardized procedure, and were rescheduled for an elective change of seton until fistula resolution. Patients' demographics, medical history, comorbidities, overall number and time interval between seton placements, tolerance, and morbidity of the procedure were recorded.

RESULTS

A total of 200 consecutive patients had loose seton placement. 69.5 % (n = 139) were males, and mean age was 42.6 years. The median number of setons required for each patient was 3 (range 1-8; mean 2.84). The mean interval between changes was 3.08 months (range 2-4 months). All patients had successful clearance of fistula. The procedure was well tolerated in 96 % of patients (n = 187). Only 1 % (n = 2) could not tolerate the presence of seton due to significant discomfort. Fistula recurrence rate was 6 % (n = 12).

CONCLUSIONS

Recently, newer treatment modalities have been reported with enthusiasm. However, there remains a lack of strong statistical evidence of efficacy to support their use. Overall, loose seton placement remains a well-tolerated, pragmatic low-cost solution to this common and difficult condition as evident by our study.

The treatment of anal fistulas with biologically derived products: is innovation better than conventional surgical treatment? An update

New technical approaches involving biologically derived products have been applied in the treatment for anal fistulas in order to avoid the risk of fecal incontinence. The aim of this review was to evaluate the scientific evidence present in the literature regarding these techniques. Trials comparing surgery (fistulotomy, advancement mucosal flap closure and placement of seton) versus fibrin glue, fistula plug or acellular dermal matrix were considered. In fibrin glue versus traditional surgical treatment the healing rate was higher in the surgery group, and the recurrence rate was lower in the traditional surgery group, but these results were not statistically relevant. In acellular dermal matrix (ADM) versus traditional surgical treatment the recurrence rate of fistulas was significantly lower in the ADM group, but non-significant differences were recorded in incontinence and anal deformity. Our review shows that there are no significant advantages of the new techniques involving biologically derived products. Further randomized controlled trials are needed.

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.