Anal fistula plug and fibrin glue versus convetional treatment in repair of complex anal fistulas
Division of General Surgery, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada. American journal of surgery
(Impact Factor: 2.29).
06/2009; 197(5):604-8. DOI: 10.1016/j.amjsurg.2008.12.013
High transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion.
This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively.
Between 1997 and 2008, 232 patients with anal fistula were identified in the St. Paul's Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively (P < .0001).
Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.
Available from: Abubakar A Bakari
- "The operative goals for subcutaneous and submuscular fistulae are to open the tract and remove tract lining either by curettage or electrocautery. The complex or recurrent fistulae may be treated by either non-cutting setons, fibrin glue, ablation, rectal mucosal advancement flap, anal fistula plugs or combination of these in order to avoid sphincter muscle division and its attendant fecal incontinence complication. Fistulotomy is a preferred procedure for subcutaneous and submuscular fistulae whether complicated or not and has 3-5% risk of flatus and stool leakage and with more muscle cutting fecal incontinence may develop. "
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ABSTRACT: Fistula-in-ano when complicated by Fournier's gangrene is an unusual finding and always carries high morbidity. This study details our experience in managing 10 cases.
Case files of all patients managed in University of Maiduguri Teaching Hospital and Federal Medical Center of Yola and Gombe from January, 2007 to December, 2011 were retrieved from Medical Record Departments and other Hospital Records. These were analyzed for demographic, clinical and pathological variables, the type of treatment and follow-up.
A total of 10 men with a mean age of 50.5 years (35-60) were managed in the period of study. Nearly, 50% of the patients were farmers, 30% businessmen and 20% were civil servant. 7 (70%) of these patients presented with Fournier's gangrene within 4 weeks of development of fistula-in-ano and the rest within 8 weeks. 4 (40%) of these patients had inadequate drainage of their perianal abscess and 2 (20%) had incision and drainage. Another 4 (40%) had spontaneously rupture of the perianal abscess. 6 (60%) of the fistula-in-ano was submuscular, 30% subcutaneous and 10% were complex or recurrent. Nearly, 20% of patients had fistulotomy and seton application for adequate drainage. Mucosal advancement flap was performed in 5 (50%) and fistulotomy in 3 (30%) patients. Another 30% had fistulotomy and continuing sitz bath.
Cryptoglandular infection is an important cause of perianal abscesses and fistula-in-ano and if poorly managed results in Fournier's gangrene. Early broad spectrum parenteral antibiotic therapy and primary surgical treatment can prevent Fournier's gangrene.
Available from: Valeria Fiaschetti
- "Besides, the treatment of complex anal fistulas is still a challenge for the colorectal surgeon with variable success rate reported in different trials [4,5]. "
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ABSTRACT: Several techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. We conducted a prospective study to assess type of presentation, treatment strategy and outcome over a 5-year period.
Between 1st January 2005 and 31st March 2011,247 patients presenting with anal fistulas were treated at the University Hospital Tor Vergata and were included in the present prospective study. Mean age was 47 years (range 16-76 years); minimum follow-up period was 6 months (mean 40, range 6-74 months).Patients were treated using 4 operative approaches: fistulotomy, fistulectomy, seton placement and rectal advancement flap. Data analyzed included: age, gender, type of fistula, operative intervention, healing rate, postoperative complications, reinterventions and recurrence.
Etiologies of fistulas were cryptoglandular (n = 218), Crohn's disease (n = 26) and Ulcerative Colitis (n = 3). Fistulae were classified as simple -intersphincteric 57 (23%), low transphincteric 28 (11%) and complex -high transphicteric 122 (49%), suprasphincteric 2 (0.8%), extrasphinteric 2 (0.8%), recto-vaginal 7 (2.8%) Crohn 26 (10%) and UC 3 (1.2%).The most common surgical procedure was the placement of seton (62%), usually applied in case of complex fistulae and Crohn's patients.Eighty-five patients (34%) underwent fistulotomy, mainly for intersphincteric and mid/low transphincteric tracts. Crohn's patients were submitted to placement of one or more loose setons.The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%). Three cases of major incontinence (1.3%) were detected during the follow-up period; Furthermore, three patients complained minor incontinence that was successfully treated by biofeedback and permacol injection into the internal anal sphincter.
This prospective audit demonstrates an high proportion of complex anal fistulae treated by seton placement that was the most common surgical technique adopted to treat our patients as a first line. Nevertheless, a good outcome was achieved in the majority of patients with a limited rate of faecal incontinence (6/247 = 2.4%). New technologies provide promising alternatives to traditional methods of management particularly in case of complex fistulas. There is, however, a real need for high-quality randomized control trials to evaluate the different surgical and non surgical treatment options.
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ABSTRACT: Fragestellung und Hintergrund
Die optimale Behandlungsmethode bei hohen/komplexen Analfisteln ist unklar. Hier wurden die Ergebnisse eines Operateurs bei proximalen Fisteln über einen Zeitraum von 10 Jahren untersucht.
Patienten und Methodik
Demographische und Behandlungsdaten sowie eine Fistelanatomie wurden für alle Patienten aufgezeichnet, die sich einem Eingriff wegen Analfisteln unterzogen. Es wurden die Ergebnisse aller Patienten dokumentiert, die mindestens 4 Wochen nachverfolgt worden waren.
Insgesamt 180 Patienten wurden untersucht. Ergebnisdaten waren für 52 niedrige und 84 hohe Fisteln verfügbar. Bei 50 niedrigen und 48 hohen Fisteln wurde eine Fistulotomie durchgeführt mit Heilungsraten von 98 bzw. 96%. Bei 2 Patienten mit proximalen Fisteln traten Rezidive auf. Die Symptome einer Kontinenzstörung waren nach Fistulotomie bei niedrigen und hohen Fisteln vergleichbar. Die Behandlung einer proximalen Fistel mittels Fadendrainage hatte gegenüber einer Fistulotomie eine geringere Rate unbeabsichtigter Inkontinenz für Flatus, aber eine ähnliche Rate von minimalem Stuhlschmieren.
Die Fistulotomie niedriger und hoher Analfisteln ist effektiv und mit einer vergleichbaren, vorhersagbaren Rate geringer Sphinkterstörungen assoziiert, wobei ein Drittel bis ein Viertel der Patienten von geringem Verlust von Flatus und Mukus betroffen sind. Patienten mit proximalen Fisteln können geheilt werden. Im Zweifelsfall sollte jedoch vor dem definitiven Eingriff eine zweite Meinung von einem Expertenzentrum eingeholt werden.
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