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Vollebregt PF, Vander Mijnsbrugge GJ, Molenaar CBH, Felt‐Bersma RJF. Efficacy of Permacol injection for perianal fistulas in a tertiary referral population: poor outcome in patients with complex fistulas. Colorectal Dis 2021; 23:2119-2126. [PMID: 33955138 PMCID: PMC8453864 DOI: 10.1111/codi.15696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/13/2021] [Accepted: 04/10/2021] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Paul F. Vollebregt
- Department of Gastroenterology and HepatologyAmsterdam UMCAmsterdam Gastroenterology Endocrinology MetabolismVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | | | | | - Richelle J. F. Felt‐Bersma
- Department of Gastroenterology and HepatologyAmsterdam UMCAmsterdam Gastroenterology Endocrinology MetabolismVrije Universiteit AmsterdamAmsterdamThe Netherlands,Proctos KliniekBilthovenThe Netherlands
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Gorgun E, Sengun B. Laser fistula surgery [Filac]: When and how? SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1016/j.scrs.2019.100706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Permacol™ collagen paste for cryptoglandular and Crohn’s anal fistula. Tech Coloproctol 2019; 23:135-141. [DOI: 10.1007/s10151-019-01932-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 01/21/2019] [Indexed: 12/18/2022]
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Comparison of porcine collagen paste injection and rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a 2-year follow-up study. Int J Colorectal Dis 2018; 33:1723-1731. [PMID: 30187158 DOI: 10.1007/s00384-018-3154-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2018] [Indexed: 02/04/2023]
Abstract
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.
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Schiano di Visconte M, Braini A, Moras L, Brusciano L, Docimo L, Bellio G. Permacol Collagen Paste Injection for Treatment of Complex Cryptoglandular Anal Fistulas: An Observational Cohort Study With a 2-Year Follow-up. Surg Innov 2018; 26:168-179. [PMID: 30339103 DOI: 10.1177/1553350618808120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
| | - Andrea Braini
- 2 "Santa Maria Degli Angeli" Hospital, Pordenone, Italy
| | - Luana Moras
- 3 Azienda Sanitaria Universitaria Integrata di Trieste, Italy
| | - Luigi Brusciano
- 4 University of Study of Campania "Vanvitelli" Naples, Italy
| | - Ludovico Docimo
- 4 University of Study of Campania "Vanvitelli" Naples, Italy
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Cheung FY, Appleton ND, Rout S, Kalaiselvan R, Nicholson JA, Samad A, Chadwick M, Rajaganeshan R. Video-assisted anal fistula treatment: a high volume unit initial experience. Ann R Coll Surg Engl 2018; 100:37-41. [PMID: 29046093 PMCID: PMC5849203 DOI: 10.1308/rcsann.2017.0187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.
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Affiliation(s)
- FY Cheung
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - ND Appleton
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - S Rout
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - R Kalaiselvan
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - JA Nicholson
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - A Samad
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - M Chadwick
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - R Rajaganeshan
- Department of General Surgery, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
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Fabiani B, Menconi C, Martellucci J, Giani I, Toniolo G, Naldini G. Permacol™ collagen paste injection for the treatment of complex anal fistula: 1-year follow-up. Tech Coloproctol 2017; 21:211-215. [PMID: 28210857 DOI: 10.1007/s10151-017-1590-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- B Fabiani
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
| | - C Menconi
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
| | - J Martellucci
- General, Emergency and Minimaly Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy.
| | - I Giani
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
| | - G Toniolo
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
| | - G Naldini
- Proctological and Perineal Surgical Unit, Department of Gastroenterology, Cisanello University Hospital, Pisa, Italy
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Mascagni D, Pironi D, Pontone S, Tonda M, Eberspacher C, Panarese A, Miscusi G, Grimaldi G, Catania A, Santoro A, Filippini A, Sorrenti S. Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient. Aging Clin Exp Res 2017; 29:101-108. [PMID: 27830517 DOI: 10.1007/s40520-016-0652-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/12/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long. AIMS The aim of this study was to evaluate the possibility of treating the abscess and the fistula tract in one procedure with total fistulectomy, sphincteroplasty and an almost complete closure of the residual cavity, thus reducing the healing time in older patients. METHODS A non-randomized single-centre series of 86 patients from 2007 to 2012 with low-medium trans-sphincteric perianal fistula (< 30% of external sphincter involvement) with or without synchronous perianal abscess were treated with total fistulectomy, sphincteroplasty and closure of the residual cavity technique. RESULTS Success rate was 97.7% with a healing time of 4 weeks; overall morbidity was 16.2%; recurrence rate was 2.3%; no major alterations of continence were observed. DISCUSSION Fistulectomy, sphincteroplasty and closure of the residual cavity are associated with a low rate of recurrence and good faecal continence preservation in older patients. This technique can be safely used even with a concomitant perianal abscess, with reduction in healing time and in the number of surgical procedures needed. CONCLUSIONS Total fistulectomy with sphincteroplasty and partial closure of the residual cavity, as described, is a safe procedure but has to be performed by dedicated colorectal surgeons.
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Affiliation(s)
| | - Daniele Pironi
- Department of Surgical Sciences, Sapienza University, Rome, Italy.
| | - Stefano Pontone
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Maya Tonda
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | | | | | | | | | - Antonio Catania
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Alberto Santoro
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Angelo Filippini
- Department of Surgical Sciences, Sapienza University, Rome, Italy
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Narang SK, Keogh K, Alam NN, Pathak S, Daniels IR, Smart NJ. A systematic review of new treatments for cryptoglandular fistula in ano. Surgeon 2016; 15:30-39. [PMID: 26993759 DOI: 10.1016/j.surge.2016.02.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 01/18/2016] [Accepted: 02/09/2016] [Indexed: 12/11/2022]
Abstract
AIM In 2007 the ACPGBI published a position statement on the management of cryptoglandular fistula in ano. Over the last seven years a number of new treatments have been developed and the aim of this systematic review was to assess their effectiveness. METHOD A systematic review of all English language literature relevant to novel treatment strategies for cryptoglandular fistula in ano, published between 1 January 2007 and 31 Dec 2014 was carried out using MEDLINE (PubMed and Ovid), EMBASE (Ovid) and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Technical notes, commentaries, letters and meeting abstracts were excluded. The different treatments were assessed with regards to fistula closure rate in relation to length of follow up and reported complications. RESULTS Seventy potential articles published between 1 January 2007 and 31 December 2014 were identified from the initial literature search. Twenty-one articles were included for final analysis although only two were randomized controlled trials, the remainder being retrospective or prospective series. CONCLUSION This systematic review has demonstrated that whilst there have been technological advances to treat complex cryptoglandular fistula in ano, these are in an early stage of evolution and although early results were promising they are difficult to reproduce. Longer follow up data is not currently available and these treatments should not be introduced without further evidence.
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Affiliation(s)
- Sunil K Narang
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - Kenneth Keogh
- North Bristol NHS Foundation Trust, Frenchay Hospital, Frenchay Park Road, Frenchay, Bristol, BS16 1LE, UK
| | - Nasra N Alam
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - Samir Pathak
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - Ian R Daniels
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK
| | - Neil J Smart
- Exeter Surgical Health Services Research Unit (HeSRU), Royal Devon & Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon, EX2 5DW, UK.
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Altomare DF. Anal fistula closure with FiLaC: new hope or the same old story? Tech Coloproctol 2015; 19:441-2. [PMID: 26187539 DOI: 10.1007/s10151-015-1347-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/06/2015] [Indexed: 12/30/2022]
Affiliation(s)
- D F Altomare
- Department of Emergency and Organ Transplantation, Aldo Moro University, Bari, Italy,
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