Treatment of Fistula-In-Ano with Fistula Plug - a Review Under Special Consideration of the Technique

Predictors of recurrence and long-term patient reported outcomes following surgical repair of anal fistula, a retrospective analysis

PURPOSE

Surgery for anal fistulas can result in devastating complications, including reoperations and fecal incontinence. There is limited contemporary evidence comparing outcomes since the adoption of the ligation of intersphincteric fistula tract procedure into mainstream practice. The purpose of this study is to compare recurrence rates and long-term outcomes of anal fistula following repair.

METHODS

Data was collected from the electronic medical records or patient reported outcomes from patients aged 18 or older with a primary or recurrent cryptoglandular anal fistula. Primary outcome was recurrence defined as the identification of at least one fistula os or a high clinical suspicion of anal fistula. Secondary outcomes included fecal incontinence and postoperative quality of life.

RESULTS

A total of 171 patients underwent definitive surgical repairs for their anal fistula. So 66.5% had a simple fistula, and 33.5% had a complex fistula. Of the 171 patients, 12.5% had a recurrence. The recurrence rates were 5.9% for simple fistula and 25.4% for complex fistula. Predictors of recurrence included diabetes mellitus, history of anorectal abscess, complex fistula, and sphincter sparing surgery. LIFT or plug/biologic procedures were both associated with a 50% or greater recurrence rate. No significant differences were found in fecal incontinence or associated quality of life between sphincter sparing or non-sphincter sparing surgical resections.

CONCLUSION

The study provides insights into the long-term outcomes of surgical repair for anal fistula. We demonstrate that sphincter sparing operations are associated with increased recurrence, meanwhile, non-sphincter sparing surgeries did not increase the risk of fecal incontinence or worsen quality of life.

Improved fistula plug outcome depends on the type of plug: a single-centre retrospective study

AIM

Fistula-in-ano is a common condition that is potentially difficult to treat. In recent years 'sphincter-sparing' procedures have increased in popularity due to the lower rates of reported complications, such as incontinence. One such treatment is the fistula plug, which has seen varied success compared with other techniques. There are currently several plugs on the market and it is possible that difference in outcomes could be linked to the type of plug used. The aim of this study was to compare healing and complication rates between two fistula plugs in a single tertiary referral centre in the UK.

METHOD

We conducted a single-centre retrospective analysis of all patients over the age of 18 years who underwent elective fistula plug insertion, with two different fistula plugs over a 13-year period.

RESULTS

A total of 113 patients underwent fistula plug insertion (plug A n = 90; plug B n = 23). Plug B had been on the market for the final 4 years of the study period, hence the differing patient numbers. There was no difference in patient demographics, fistula type or aetiology of the fistula between the two plugs. Plug B had a significantly higher fistula healing rate compared with plug A (56.5% vs. 12.2%; p < 0.005). A quarter of all patients experienced a complication, 93% being those who had fistula plug A inserted. The most common complication was extrusion of the plug within 72 h of insertion.

CONCLUSION

This study demonstrated significantly different outcomes according to the type of fistula plug used. Whilst current randomized controlled trials have not found a significant difference in healing rates when comparing one type of fistula plug to other treatment modalities, this study suggests that plug type may influence efficacy.

Treatment of anal fistula using a decellularized porcine small intestinal submucosa plug: A non-inferiority trial

BACKGROUND

Using small intestinal submucosa (SIS) has increasingly become the standard method for the treatment of anal fistula. The porcine SIS manufactured by Biosis Healing is a novel biological material that has several advantages for the safe and effective repair of tissues. Our study aimed to verify the efficacy and safety of the decellularized porcine SIS (VIDASIS) anal fistula plug.

METHODS

We conducted a non-inferiority multicenter, randomized, controlled clinical trial involving patients with chronic anal fistula. Patients from 3 centers across China were randomized 1:1 to Biosis SIS vs commercial SIS. The primary endpoint was the healing rate and secondary endpoints included recurrence within 6 months, rate of copracrasia, healing time, pain using a visual analog scale, and patient and doctor satisfaction.

RESULTS

A total of 186 patients were randomized. Of these, 82 patients in the Biosis SIS and 81 in the control (commercial) SIS completed the trial (per-protocol set). The healing rate at the 6-month follow-up (full analysis set) was 92.0% for the Biosis SIS and 89.8% for the control SIS (P = .620). The rate difference of 2.2% (full analysis set; 95% confidence interval: -6.4% and 10.7%, respectively) was within the pre-specified non-inferiority margin of -10%. There were no differences between the 2 groups with regard to the secondary endpoints. No serious adverse event or death occurred.

CONCLUSION

Our study shows that the VIDASIS anal fistula plug manufactured by the company Biosis Healing is safe and effective and is not inferior to existing commercial SIS materials.

Is Fistulotomy with Marsipulization more Effective than Fistulectomy alone for Low Fistula in Ano?

Background Fistula in ano is a very common perianal condition seen in outpatient departments. Fistulotomy and fistulectomy are two conventional options of surgery. The present study is designed to observe wound healing time and mean postoperative pain score in the comparison of outcome of the fistulectomy to fistulotomy with marsupialization.

Methods This prospective randomized trial was conducted in the surgical department of the Civil Hospital Karachi for a period of 12 months, in which 60 patients with low anal fistula were divided into 2 groups. Thirty patients in group A were treated with fistulectomy, and 30 in group B were treated with fistulotomy with marsupialization. The postoperative pain severity was assessed after 24 hrs through a visual analogue scale and on weekly and fortnightly follow-ups for 6 weeks. Wound healing was assessed by clinical examination on weekly and fortnightly follow-ups for 6 weeks to estimate the mean healing time.

Results The mean pain score was significantly lower in group B in comparison to group A (3.6 ± 1.99 versus 2.40 ± 1.52; p = 0.01). The mean wound healing time was shorter in group B in comparison to group A (4.23 ± 0.77 versus 5.80 ± 0.41 weeks; p = 0.0005).

Conclusion Fistulotomy with marsupialization is a simple, easy, and more effective method than fistulectomy for the treatment of simple perianal fistula.

Safety of Allogeneic Adipose Tissue-Derived Mesenchymal Stem Cells for the Treatment of Complex Perianal Fistulas Not Associated With Crohn's Disease: A Phase I Clinical Trial

BACKGROUND

Anal fistula treatment aims to eradicate the fistula, preserve the sphincter, prevent recurrence, and allow an early return to daily activities for the patient. Because of the difficulty of achieving these goals, stem cell-based therapy has emerged for the treatment of complex perianal fistula with promising results.

OBJECTIVE

The objective of this study was to evaluate the safety of allogeneic mesenchymal stem cells in the treatment of complex anal fistula in patients without Crohn's disease.

DESIGN

This was a prospective nonrandomized phase I clinical trial.

SETTINGS

This study was conducted at a second-level hospital.

PATIENTS

Twenty consecutive patients diagnosed with a complex fistula were included.

INTERVENTIONS

All patients received 40 × 106 allogeneic mesenchymal stem cells. In patients with 2 tracts, 20 × 106 stem cells were applied on each tract.

MAIN OUTCOME MEASURES

The patients were discharged 24 hours after the procedure and were evaluated at 1, 2, 4, 8, 16, and 24 weeks after the application. The long-term follow-up was performed 1 year after the procedure.

RESULTS

The procedure was performed in a total of 20 patients from October 1, 2016, to October 31, 2017; 1 patient was eliminated from the final data analysis. No adverse effects were reported within the first 24 hours, and all the patients were discharged asymptomatic. Three patients (15%) presented with perianal abscess. In 1 patient, the abscess appeared at the fourth week, and, in the other 2 patients, the abscess was diagnosed at week 8. Complete closure was achieved in 13 (69%) patients.

LIMITATIONS

This was a nonrandomized controlled trial.

CONCLUSION

The use of allogeneic mesenchymal stem cells as a treatment is a safe option for the management of complex perianal fistula not associated with Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B443.

SEGURIDAD DE LAS CLULAS MADRE MESENQUIMALES ALOGNICAS DERIVADAS DEL TEJIDO ADIPOSO PARA EL TRATAMIENTO DE FSTULAS PERIANALES COMPLEJAS NO ASOCIADAS CON LA ENFERMEDAD DE CROHN ENSAYO CLNICO DE FASE I

ANTECEDENTES:El tratamiento de la fístula anal tiene como objetivo erradicar la fístula, preservar el esfínter, prevenir la recurrencia y permitir un retorno temprano a las actividades diarias del paciente. Debido a la dificultad de alcanzar estos objetivos, ha surgido una terapia basada en células madre para el tratamiento de la fístula perianal compleja con resultados prometedores.OBJETIVO:El objetivo de este estudio fue evaluar la seguridad de las células madre mesenquimales alogénicas en el tratamiento de la fístula anal compleja en pacientes sin enfermedad de Crohn.DISEÑO:Este fue un ensayo clínico prospectivo no aleatorizado de fase I.AMBIENTE:Este estudio se realizó en un hospital de segundo nivel.PACIENTES:Veinte pacientes consecutivos diagnosticados de fístula compleja.INTERVENCIONES:Todos los pacientes recibieron 40 x 106 células madre mesenquimales alogénicas, en pacientes con dos tractos, se aplicaron 20 x 106 células madre en cada tracto.PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes fueron dados de alta 24 horas después del procedimiento y fueron evaluados 1, 2, 4, 8, 16, 24 semanas después de la aplicación. El seguimiento a largo plazo se realizó un año después del procedimiento.RESULTADOS:El procedimiento se realizó en un total de 20 pacientes desde el 1 de octubre de 2016 al 31 de octubre de 2017; un paciente fue eliminado del análisis de datos final. No se informaron efectos adversos en las primeras 24 horas, todos los pacientes fueron dados de alta asintomáticos. Tres pacientes (15%) presentaron absceso perianal. En un paciente, el absceso apareció a la cuarta semana y en los otros dos pacientes el absceso se diagnosticó en la octava semana. El cierre completo se logró en 13 (69%) de los pacientes.LIMITACIONES:Este fue un ensayo controlado no aleatorio.CONCLUSIÓN:El uso de células madre mesenquimales alogénicas como tratamiento es una opción segura para el manejo de la fístula perianal compleja no asociada con la enfermedad de Crohn. Consulte Video Resumen en http://links.lww.com/DCR/B443.

A Multicenter Randomized Controlled Trial Comparing Safety, Efficacy, and Cost-effectiveness of the Surgisis Anal Fistula Plug Versus Surgeon's Preference for Transsphincteric Fistula-in-Ano: The FIAT Trial

OBJECTIVE

To undertake a randomized comparison of the Biodesign Surgisis anal fistula plug against surgeon's preference in treating cryptoglandular transsphincteric fistula-in-ano.

SUMMARY BACKGROUND DATA

The efficacy of the Biodesign Surgisis anal fistula plug in healing anal fistulae is uncertain.

METHODS

Participants were randomized to the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, Ligation of the Intersphincteric Fistula Tract procedure). The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and reintervention rates.

RESULTS

Between May 2011 and March 2016, 304 participants were randomized to fistula plug or surgeon's preference. No differences were seen in FIQoL between the 2 groups at 12 months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12 months. Fecal incontinence rates improved marginally in both the groups. Complications and reinterventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs 25/137, 18%; P=0.002). The mean total costs were £2738 (s.d. £1151) for the fistula plug and £2308 (s.d. £1228) for the surgeon's preference group (mean difference +£430, P=0.0174). The average total quality adjusted life years (QALYs) gained was marginally higher in the fistula plug group. The fistula plug was 35% to 45% likely to be cost-effective across a willingness to pay threshold of £20,000 to £30,000 / QALY.

CONCLUSIONS

The Biodesign Surgisis anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12 months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS.

Long-Term Clinical Results of Use of an Anal Fistula Plug for Treatment of Low Trans-Sphincteric Anal Fistulas

BACKGROUND An anal fistula plug is a sphincter-sparing procedure that uses biological substances to close an anorectal fistula. This study aimed to evaluate the long-term therapeutic effect of an anal fistula plug procedure in patients with trans-sphincteric fistula-in-ano and to determine the risk factors affecting fistula healing. MATERIAL AND METHODS A single-center retrospective study was performed assessing long-term treatment outcomes of patients with low trans-sphincteric anal fistulas who initially underwent anal fistula plug procedures between August 2008 and September 2012. Risk factors affecting fistula healing were identified using univariate and multivariate analyses. RESULTS A total of 135 patients who had low trans-sphincteric anal fistulas and underwent anal fistula plug procedures were analysed. The overall healing rate was 56% (75/135) with a median follow-up time of 8 years (range, 72-121 months). The primary reasons for treatment failure were plug extrusion (n=12, 20%) and surgical site infection (n=9, 15%), occurring within 30 days after surgery. Multiple logistic regression analysis showed that the duration of anal fistula ≥6 months was significantly associated with treatment failure using an anal fistula plug (OR=3.187, 95% CI: 1.361-7.466, P=0.008). Of the patients who failed initial treatment with an anal fistula plug, 6 (9%) had anal fistulas that healed spontaneously after 2-3 years without additional treatment. CONCLUSIONS As a sphincter-preserving procedure, the anal fistula plug can effectively promote healing of low trans-sphincteric anal fistulas. The long-term efficacy is good and the procedure warrants wider use in clinical practice.

Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis

AIM

Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease.

METHOD

The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019.

RESULTS

Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study.

CONCLUSION

FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.

Effects of an anal fistula plug on anal function after surgery for treatment of a trans-sphincteric anal fistula

PURPOSE

The aim of this study was to evaluate the anal function in patients with trans-sphincteric anal fistulas who underwent an anal fistula plug procedure, and analyze risk factors that might affect post-operative anal function.

METHODS

This was an observational, retrospective study of patients diagnosed with trans-sphincteric anal fistulas and initially underwent anal fistula plug procedures between August 2008 and September 2012 at our institute. The analysis includes clinical characteristics, anal fistula healing, and the Wexner score for pre- and post-operative anal function (0 = no incontinence to 20 = complete incontinence).

RESULTS

A total of 123 patients who had an adequate follow-up in the end were included. The median duration of follow-up was 8 years (range 72-121 months). The overall healing rate was 56% (69/123), and 33 (26.8%) patients had decreased anal function after surgery. The post-operative Wexner score on anal function was significantly higher than that before the operation (p < 0.001), as well as scores of gas, liquid stool, solid stool incontinence, and alteration in lifestyle (p < 0.05). Based on multiple logistic regression analysis, a high body mass index (p < 0.001) and long distance between the external opening and anal verge (p = 0.003) were significantly associated with a decline in post-operative anal function.

CONCLUSIONS

As a sphincter-preserving technique for the treatment of anal fistulas, the anal fistula plug procedure might impair the anal function. Especially for patients with obesity or long distance between the external opening of anal fistula and anal verge, the reduced anal function is more likely to occur after treatment with anal fistula plug therapy.

Anal fistula plug versus surgeon's preference for surgery for trans-sphincteric anal fistula: the FIAT RCT

BACKGROUND

The aim of fistula surgery is to eradicate the disease while preserving anal sphincter function. The efficacy of the Surgisis^® anal fistula plug (Cook Medical, Bloomington, IN, USA) in the treatment of trans-sphincteric fistula-in-ano has been variably reported.

OBJECTIVES

To undertake a randomised comparison of the safety and efficacy of the Surgisis anal fistula plug in comparison with surgeon's preference for the treatment of trans-sphincteric anal fistulas.

DESIGN

A randomised, unblinded, parallel-arm, prospective, multicentre clinical trial.

SETTING

Hospitals in the UK NHS involving colorectal surgeons accredited by the Association of Coloproctology of Great Britain and Ireland.

PARTICIPANTS

Adult patients suffering from trans-sphincteric fistula-in-ano of cryptoglandular origin.

INTERVENTIONS

Patients were randomised on a 1 : 1 basis to either the fistula plug or the surgeon's preference [e.g. fistulotomy, cutting seton, advancement flap or ligation of intersphincteric fistula tract (LIFT) procedure].

MAIN OUTCOME MEASURES

The primary outcome measure was quality of life as measured by the Faecal Incontinence Quality of Life (FIQoL) questionnaire at 12-month follow-up. Secondary outcome measures included clinical and radiological fistula healing rates, faecal incontinence rates, complications rates, reintervention rates and cost-effectiveness.

RESULTS

Between May 2011 and March 2016, 304 participants were recruited (152 fistula plug vs. 152 surgeon's preference). No difference in FIQoL score between the two trial groups was seen at the 6-week, 6-month or 12-month follow-up. Clinical evidence of fistula healing was reported in 66 of 122 (54%) participants in the fistula plug group and in 66 of 119 (55%) participants in the surgeon's preference group at 12 months. Magnetic resonance imaging (MRI) showed fistula healing in 54 of 110 (49%) participants in the fistula plug group and in 63 of 112 (56%) participants in the surgeon's preference group. Variation in 12-month clinical healing rates was observed: 55%, 64%, 75%, 53% and 42% for fistula plug, cutting seton, fistulotomy, advancement flap and LIFT procedure, respectively. Faecal incontinence rates were low at baseline, with small improvement in both groups post treatment. Complications and reinterventions were frequent. The mean total costs were £2738 [standard deviation (SD) £1151] in the fistula plug group and £2308 (SD £1228) in the surgeon's preference group. The average total quality-adjusted life-years (QALYs) gain was much smaller in the fistula plug group (0.829, SD 0.174) than in the surgeon's preference group (0.790, SD 0.212). Using multiple imputation and probabilistic sensitivity analysis, and adjusting for differences in baseline EuroQol-5 Dimensions, three-level version utility, there was a 35-45% chance that the fistula plug was as cost-effective as surgeon's preference over a range of thresholds of willingness to pay for a single QALY of £20,000-30,000.

LIMITATIONS

Limitations include a smaller sample size than originally calculated, a lack of blinding that perhaps biased patient-reported outcomes and a lower compliance rate with MRI at 12-month follow-up.

CONCLUSIONS

The Surgisis anal fistula plug is associated with similar FIQoL score to surgeon's preference at 12-month follow-up. The higher costs and highly uncertain and small gains in QALYs associated with the fistula plug mean that this technology is unlikely to be considered a cost-effective use of resources in the UK NHS.

FUTURE WORK

Further in-depth analysis should consider the clinical and MRI characteristics of fistula-in-ano in an attempt to identify predictors of fistula response to treatment.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN78352529.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 21. See the NIHR Journals Library website for further project information.

Sphincter-saving therapy for fistula-in-ano: long-term follow-up after FiLaC®

BACKGROUND

The treatment of anal fistula remains a challenge between maintaining continence and radical surgery to prevent recurrence. Fistula-tract Laser Closure (FiLaC^®) is a sphincter-saving technique using a radial emitting laser fibre to close the fistula tract. The aim of this study was to report long-term outcomes in patients who received FiLaC^® therapy for transsphincteric and intersphincteric anal fistula between January 2011 and December 2017.

METHODS

A retrospective study was performed on patients who were treated with FiLaC^®- for a transsphincteric and intersphincteric anal fistula at our institution between January 2011 and December 2017. In all patients, the FiLaC^® procedure was combined with a closure of the internal orifice using a simple 3-0 Z stitch. Patient characteristics, previous proctological history, healing rates, failures and postoperative continence were investigated.

RESULTS

The study included 83 patients [mean age 50.01 ± 14.59 years. 64 (77.1%) males] with a mean follow-up period of 41.99 (± 21.59) months (range 4-87 months). Thirteen patients (15.7%) had a recurrent fistula. 65 patients (78.3%) had undergone prior abscess drainage with insertion of a seton. The primary healing rate was 74.7% (62 of 83 patients) overall. Eleven (13.3%) of the 21 patients (25.3%) who failed FiLaC^®-therapy underwent a second operation. In eight cases, Re-FiLaC^® and in three cases, fistulectomy with closure of the internal orifice was performed. Afterwards 6 (54.5%) of these 11 patients could be considered cured: 3 who had fistulectomy and three who had Re-FiLaC^® treatment. The overall healing rate after second FiLaC^® was 78.3% (65 of 83 patients) while the overall healing rate for FiLaC^® therapy combined with any second procedure was 81.9% (68 of 83 patients). The follow-up period in this group of 11 patients who received re-operation was 38 months (range 13-84 months). Changes in continence occurred in eight patients (9.6%). No patient reported major incontinence postoperatively.

CONCLUSIONS

The FiLaC^® procedure is associated with good healing rates in long-term follow-up and should be considered as a treatment option for transsphincteric and intersphincteric anal fistulae, especially due to the low complication rate and low risk of sphincter injury.

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.

Five years of experience with the FiLaC™ laser for fistula-in-ano management: long-term follow-up from a single institution

Background

There are limited data available concerning endofistular therapies for fistula-in-ano, with our group reporting the first preliminary outcomes of the use of the radial fibre Fistula laser Closing (FiLaC ™) device.

Methods

The aim of this study was to assess a cohort of anal fistulae managed with laser ablation plus definitive flap closure of the internal fistula opening over a long-term follow-up. Factors governing primary healing success and secondary healing success (i.e. success after one or two operations) were determined.

Results

The study analysed 117 patients over a median follow-up period of 25.4 months (range 6–60 months) with 13 patients (11.1%) having Crohn’s-related fistulae. No incontinence to solid and liquid stool was reported. Minor incontinence to mucus and gas was observed in two cases (1.7%), and a late abscess treated in one case (0.8%). The primary healing rate was 75/117 (64.1%) overall, and 63.5% for cryptoglandular fistulae versus 69.2% for Crohn’s fistulae, respectively. Of the 42 patients who failed FiLaC™ 31 underwent a second operation (“Re-FiLaC™”, fistulectomy with sphincter reconstruction or fistulotomy). The secondary healing rate, defined as healing of the fistula at the end of the study period, was 103/117 (88.0%) overall and 85.5% for cryptoglandular fistulae versus 92.3% for Crohn’s fistulae. A significantly higher primary success rate was observed for intersphincteric-type fistulae with primary and secondary outcome unaffected by age, gender, presence of Crohn’s disease, number of prior surgeries and the type of flap designed to close the internal fistula opening.

Conclusions

There is a moderate primary success rate using first-up FiLaC™ treatment. If FiLaC™ fails, secondary success with repeat FiLaC™ or other approaches was high. The minimally invasive FiLaC™ approach may therefore represent a sensible first-line treatment option for anal fistula repair.

An experience with video-assisted anal fistula treatment (VAAFT) with new insights into the treatment of anal fistulae

BACKGROUND

The aim of this retrospective study was to assess our experience of 41 patients with anal fistulae treated with video-assisted anal fistula treatment (VAAFT).

METHODS

Forty-one consecutive patients with cryptoglandular anal fistulae were included. Patients with low intersphincteric anal fistulae or those with gross perineal abscess were excluded. Eleven (27 %) patients had undergone prior fistula surgery with 5 (12 %) having had three or more previous operations.

RESULTS

All patients underwent the diagnostic phase as well as diathermy and curettage of the fistula tracts during VAAFT. Primary healing rate was 70.7 % at a median follow-up of 34 months. Twelve patients recurred or did not heal and underwent a repeat VAAFT procedure utilising various methods of dealing with the internal opening. There was a secondary healing rate of 83 % with two recurrences. Overall, stapling of the internal opening had a 22 % recurrence rate, while anorectal advancement flap had a 75 % failure rate. There was no recurrence seen in six cases after using the over-the-scope-clip (OTSC(®)) system to secure the internal opening.

CONCLUSIONS

VAAFT is useful in the identification of fistula tracts and enables closure of the internal opening. Adequate closure is essential with the method used to close large or fibrotic internal openings being the determining factor for success or failure. The OTSC system delivered the most consistent result without leaving a substantial perianal wound. Ensuring thorough curettage and drainage of the tract during VAAFT is also important to facilitate healing. We believe that this understanding will bring about a decrease in the high recurrence rates currently seen in many series of anal fistulae.