Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas

Introduction

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.

Methods

This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively.

Results

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).

Conclusions

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.     

Surgical management of anal fistulae: a systematic review

Objective  The anal fistula has been a common surgical ailment reported since the time of Hippocrates but little systematic evidence exists on its management. We aimed to systematically review the available studies relating to the surgical management of anal fistulas. Method  Studies were identified from PubMED, EMBASE, Cochrane Controlled Trials Register, ClinicalTrials.Gov and Current Controlled Trials. All uncontrolled, nonrandomized, retrospective studies, duplications or those unrelated to the surgical management of anal fistulas were excluded. Results  The search strategy revealed 443 trials. After exclusions 21 randomized controlled trials remained evaluating: fistulotomy vs fistulectomy (n = 2), seton treatment (n = 3), marsupialization (n = 2), glue therapy (n = 3), anal flaps (n = 3), radiosurgical approaches (n = 2), fistulotomy/fistulectomy at time of abscess incision (n = 5) and intra‐operative anal retractors (n = 1). Two meta‐analyses evaluating incision and drainage alone vs incision + fistulotomy were obtained. Conclusion  Marsupialization after fistulotomy reduces bleeding and allows for faster healing. Results from small trials suggest flap repair may be no worse than fistulotomy in terms of healing rates but this requires confirmation. Flap repair combined with fibrin glue treatment of fistulae may increase failure rates. Radiofrequency fistulotomy produces less pain on the first postoperative day and may allow for speedier healing. Major gaps remain in our understanding of anal fistula surgery.     

Is ITP really a desirable indication for teaching laparoscopic splenectomy? Cohort study

Background : To evaluate the results of a combination of fistulectomy with a rectal advancement flap and an anal fistula plug in the treatment of transsphincteric anal fistulas.

Method : All patients with a transsphincteric fistula and a limited number of anterior intersphincteric fistulas in female patients were registered from July 1st, 2010 until November 30th, 2012.

All operations were performed by one surgeon (CdG). Patient data and results (healing, continence) were collected in a prospective database.

Results : 28 patients were treated with a healing rate of 75% after one procedure. Four out of seven patients who failed to heal underwent a redo anal fistula plug and rectal advancement flap. Three of them were cured. Cumulative healing rate was 86% after two procedures. There were four minor complications. Mean postoperative Wexner score was 0.62. Conclusion : Combination of anal fistula plug and rectal advancement flap in treating transsphincteric anal fistulas can result in good healing rates with minimal incontinence.     

The Anal Fistula Plug versus the mucosal advancement flap for the treatment of Anorectal Fistula (PLUG trial)

Background  

Low transsphincteric fistulas less than 1/3 of the sphincter complex are easy to treat by fistulotomy with a high success rate. High transsphincteric fistulas remain a surgical challenge. Various surgical procedures are available, but recurrence rates of these techniques are disappointingly high. The mucosal flap advancement is considered the gold standard for the treatment of high perianal fistula of cryptoglandular origin by most colorectal surgeons. In the literature a recurrence rate between 0 and 63% is reported for the mucosal flap advancement. Recently Armstrong and colleagues reported on a new biologic anal fistula plug, a bioabsorbable xenograft made of lyophilized porcine intestinal submucosa. Their prospective series of 15 patients with high perianal fistula treated with the anal fistula plug showed promising results.     

Outcomes of anal fistula surgery in patients with inflammatory bowel disease

Background

Anal fistulas in patients with Crohn's disease are especially difficult to manage because of nonhealing and incontinence. We reviewed our outcomes for the newer sphincter-preserving techniques of anal fistula plug and fibrin glue compared with standard treatments of advancement flap closure and seton drain insertion.

Methods

This was a retrospective study of patients with inflammatory bowel disease treated for high transsphincteric anal fistulas. The primary outcome was healing and continence at 12 weeks postoperatively.

Results

Between 1997 and 2009, 51 patients with anal fistulas and inflammatory bowel disease were identified in the St Paul's Hospital Anal Fistula Database. Postoperative healing rates at 12 weeks for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 75%, 0%, 20%, and 28%, respectively. Continence scores were not altered by these procedures.

Conclusions

Closure of the primary fistula opening in patients with inflammatory bowel disease using a biologic anal fistula plug had improved healing compared with fibrin glue, seton drain, and flap advancement. Given its low morbidity and relative simplicity, the anal fistula plug should be considered for treating high transsphincteric anal fistulas in patients with inflammatory bowel disease.     

Early Experience with the Bioabsorbable Anal Fistula Plug

PURPOSE: Management of anal fistula represents a balance between curing the condition and maintaining anal continence. Recent reports of the results of the porcine anal fistula plug have demonstrated excellent fistula healing rates without reporting significant complications. METHODS: The outcome of patients who underwent treatment for anal fistula with the Surgisis anal plug was retrospectively reviewed. RESULTS: Twenty patients were treated; three underwent concomitant anal advancement flap at the time of plug placement. Seventeen patients had a trans-sphincteric fistula, and three had an anoperineal fistula. Ten patients had previously undergone failed surgical therapy to cure their fistula, including anal advancement flap in four, muscle interposition flap in two, fistulotomy in two, and cutting seton placement in two. Mean follow-up was 7.4 months. Only 4 of 17 (24%) patients treated with the plug alone had closure of their fistula. Acute postoperative sepsis was seen in 5 of 17 (29%) patients treated with the plug alone. Four developed perianal abscesses that required incision and drainage, and one intersphincteric abscess was treated with antibiotics. Two of the patients who underwent concomitant anal advancement flaps and plug placement healed successfully. CONCLUSIONS: Contrary to other published series, the use of the Surgisis anal plug was associated with a low rate of fistula healing and a high incidence of perianal sepsis. The addition of a transanal advancement flap to the procedure may improve success rates.     

Comparison of different methods to manage supralevator rectal opening in anal fistulas: A retrospective cohort study

IntroductionSupralevator fistula-in-ano are difficult to manage. If these fistulas have an additional supralevator internal-opening in rectum apart from the primary internal-opening at the dentate line, then the management becomes even more difficult. There is no literature/guidelines available on the management of supralevator rectal opening (SRO).MethodsAll consecutive supralevator fistula-in-ano patients having a SRO were retrospectively analyzed. The operative management of SRO in these fistulas was reviewed. All the fistulas were managed by the same procedure, transanal opening of intersphincteric space (TROPIS). The latter was a modification of LIFT (ligation of intersphincteric tract) procedure in which the intersphincteric tract was opened-up in the rectum rather than ligated (as is done in LIFT). The SRO was managed in three ways, group-1:SRO was laid-open into the rectum in continuity with the primary opening at dentate line, group-2:the mucosa around SRO was cauterized, group-3:nothing could be done to SRO.ResultsOut of 836 patients operated between 2015 and 2020, 138 patients (16.5%) had supralevator extension. Amongst these, 23/138 (16.6%) patients had a SRO. 2 patients were excluded (short follow-up) and 21 patients were included in the analysis. 12/13(92%) patients in group-1, 4/5 (80%) patients in group-2 and 2/3(67%) patients in group-3 got healed (p = 0.47, Chi-square test). The overall healing rate was 18/21(86%).ConclusionsThe supralevator rectal opening (SRO) heals well irrespective of the method utilized. Thus, proper management of the primary opening at the dentate line holds the key to fistula healing and SRO is perhaps not much responsible for persistence of the fistula. However, more studies are needed to corroborate these findings.     

Diagnosis of anorectal tuberculosis by polymerase chain reaction,GeneXpert and histopathology in 1336 samples in 776 anal fistula patients

BACKGROUNDThe association of tuberculosis (TB) with anal fistulas can make its treatment quite difficult. The main challenge is timely detection of TB in anal fistulas and its proper management. There is little data available on diagnosis and management of TB in anal fistulas. AIMTo detect TB in fistula-in-ano patients were analyzed in different methods utilized.METHODSA retrospective analysis of different methods, polymerase chain-reaction (PCR), GeneXpert and histopathology (HPE), utilized to detect tuberculosis in fistula-in-ano patients, treated between 2014-2020, was performed. The sampling was done for tissue (fistula tract lining) and pus (when available). The detection rate of various tests to detect TB and prevalence rate of TB in simple vs complex fistulae were studied.RESULTSIn 1336 samples (776 patients) tested, TB was detected in 133 samples (122 patients). TB was detected in 52/703 (7.4%) samples tested by PCR-tissue, in 77/331 (23.2%) samples tested by PCR-pus, 3/197 (1.5%) samples tested with HPE-tissue and 1/105 (0.9%) samples tested by GeneXpert. To detect TB, PCR-tissue was significantly better than HPE-tissue (52/703 vs 3/197 respectively) (P = 0.0012, significant, Fisher’s exact test) and PCR-pus was significantly better than PCR-tissue (77/331 vs 52/703 respectively) (P < 0.00001, significant, Fisher’s exact test). TB fistulas were more complex than non-tuberculous fistulas [78/113 (69%) vs 278/727 (44.3%) respectively] (P < 0.00001, significant, Fisher’s exact test) but the overall healing rate was similar in tuberculous and non-tuberculous fistula groups [90/102 (88.2%) vs 518/556 (93.2%) respectively] (P = 0.10, not significant, Fisher’s exact test).CONCLUSIONThis is the largest study of anorectal TB to be published. The detection of TB by polymerase chain-reaction was significantly higher than by histopathology and GeneXpert. Amongst polymerase chain-reaction, pus had a higher detection rate than tissue. TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.     

Fistulotomy in the Tertiary Setting can Achieve High Rates of Fistula Cure with an Acceptable Risk of Deterioration in Continence

Introduction

Surgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen.

Methods

Patients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005–2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained.

Results

Eighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P?=?0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery.

Conclusions

We have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor incontinence.     

肛瘘栓填塞治疗经括约肌型肛瘘的长期疗效及预后影响因素分析

目的评估肛瘘栓填塞治疗经括约肌型肛瘘的长期愈合率及影响肛瘘愈合的因素。方法采用回顾性病例对照研究方法,分析2008年8月至2012年9月期间于首都医科大学附属北京朝阳医院普通外科接受肛瘘栓填塞治疗的207例经括约肌型肛瘘患者的临床资料。患者纳入标准:(1)符合经括约肌型肛瘘的诊断:即瘘管穿越内括约肌及外括约肌的浅、深部之间;(2)患者病例资料完整;(3)初始接受肛瘘栓填塞治疗。排除标准:(1)直肠肛管周围急性感染或病灶感染控制不佳;(2)近期行直肠肛管周围脓肿切开引流术或自行破溃者;(3)合并有恶性肿瘤;(4)克罗恩病、炎性肠病者;(5)心、肝、脑、肺、肾功能不全者;(6)各种慢性消耗性疾病造成恶病质;(7)不能耐受手术者。随访患者的肛瘘愈合情况,采用Kaplan⁃Meier法绘制肛瘘患者累计治愈率,并用单因素和多因素logistic回归分析探究影响肛瘘愈合的因素。结果全组男性186例,女性21例,年龄15~69(平均数38)岁。肛瘘病程3~60(平均数15)个月。有3例患者既往有肛周脓肿发作史并且行肛周脓肿切开引流术(均超过3个月)。随访截至2018年10月31日,失访72例(34.8%)。在135例成功随访的患者中,平均随访时间为96(75~124)个月,肛瘘愈合75例,愈合率为55.6%。Kaplan⁃Meier生存曲线显示,肛瘘治愈率随时间延长,最终稳定在55.6%。在初次接受肛瘘栓填塞治疗失败的患者中,有6例在未接受其他治疗的情况下,肛瘘自行愈合。其中,3例于术后2年、3例于术后3年自行愈合,并未再复发。2008—2012年,肛瘘栓填塞治疗的年治愈率分别为3/6、61.5%(24/39)、42.1%(24/57)、12/15和12/18。多因素logistic回归分析显示,肛瘘病程≥6个月(OR=3.187,95%CI:1.361~7.466,P=0.008)是影响肛瘘栓填塞治疗后肛瘘愈合的独立危险因素。结论肛瘘栓填塞治疗经括约肌型肛瘘长期疗效肯定,宜尽早实施。     

Bioprosthetic plugs for complex anal fistulas: an early experience

PURPOSE: The goal in the treatment of anal fistulas is to eliminate the fistula without a change in continence. No single technique exists that is appropriate for the treatment of all fistulas. Options include fistulotomy, use of setons, fibrin sealant, and advancement flaps. Recently, a bioprosthetic fistula plug has been described. The purpose of this study is to report the author's early experience with the bioprosthetic fistula plug and to compare the results of bioprosthetic plug closure of complex anal fistulas with those achieved with advancement flap repair. METHODS: A retrospective analysis of prospectively collected data was performed for patients treated with an anal fistula. Data collected included age, gender, fistula anatomy and etiology, previous repairs, comorbidities, procedure performed, pain scores, and fistula recurrence. RESULTS: Overall, 95 patients comprised the control group (43 men and 52 women), with transsphincteric or rectovaginal fistulas in 51 and 44 patients, respectively, managed by advancement flap repair of their fistula. The fistula recurred in 31 patients (32.6%) during a median follow-up of 10 months. Overall,18 patients had their fistula managed using the porcine fistula plug (12 men and 6 women), with transsphincteric or rectovaginal fistulas in 13 and 5 patients, respectively. The fistula recurred in 2 patients (12%) during a median follow-up of 6 months. CONCLUSION: Use of a porcine fistula plug for the management of complex anal fistulas is a new technique that, in the early experience, seems to yield results similar to advancement flap repair.     

Surgical options for perianal fistula in patients with Crohn's disease: A comparison of seton placement,fistulotomy, and stem cell therapy

ObjectiveThis study was designed to assess the demographic characteristics of patients with Crohn's perianal fistula (CPF) who were treated at a tertiary referral institution. Surgical outcomes were compared in groups of patients who underwent seton placement, fistulotomy, and stem cell therapy.MethodsPatients who underwent surgery for CPF between 2015 and 2017 at Asan Medical Center, Seoul, Korea, were retrospectively evaluated. Patients were divided into groups who underwent seton placement, fistulotomy, and stem cell therapy. Their clinical variables and closure rates were compared.ResultsThis study included 156 patients who underwent a total of 209 operations. More than half of the operations consisted of seton placement (67%), followed by stem cell therapy (18%) and fistulotomy (15%) patients. Of the 209 fistulas, 153 (73%) were complex, with an overall closure rate of 38% during a median follow-up of 29 months. Closure rates following fistulotomy, stem cell therapy, and seton placement were 90%, 70%, and 18%. Seton placement was more significantly frequently used than the other procedures in patients with complex fistula and those with abscesses. Of the 79 fistulas that achieved complete closure, 11 (14%) recurred. The recurrence rates did not differ among the various techniques.ConclusionSurgical treatment of CPF is dependent on lesion type. Seton placement was the primary draining procedure for complex fistulas and abscesses, resulting in low closure rates. Fistulotomy was the definite procedure for low type and simple fistula. Stem cell therapy showed high closure rates as definitive treatment, even for complex fistulas.     

Perianale Crohn-Fisteln

Background

Approximately one third of patients with Crohn’s disease develop perianal fistulas. This study was conducted to determinate outcome predictors in patients treated at a specialized multidisciplinary unit.

Patients and methods

Between May 2005 and May 2008, all patients with perianal Crohn’s fistulas were treated by the same surgeon and a gastroenterologist specialized in managing patients with Crohn’s disease. Deep fistulas were treated by fistulotomy. For high fistulas, a noncutting seton was placed followed by maintenance treatment with azathioprine and/or infliximab. “Optimal outcome” was recorded when (a) there was no need for diverting stoma, (b) complete healing was achieved by fistulotomy, or (c) fistula symptoms were under control, i.e. there was no need for treatment extension during follow-up.

Results

Thirty-four male and 32 female patients underwent 100 surgical interventions. The most frequent types of fistula were high trans-sphincteric (62%) and high intersphincteric (15%). Eleven of the 32 females presented with rectovaginal fistulae. At the study end, complete healing was observed in 12 patients and 32 had good control of fistula symptoms. Seven required proctectomy, fistula symptoms were not under control in 12, and three required diverting stoma. Altogether 44 patients (67%) achieved optimal outcome. The following factors were predictors of nonoptimal outcome by multivariate analysis: presence of Crohn’s colitis (P=0.01), age at the onset of Crohn’s disease <20 years (P=0.02), and types of fistula not suitable for fistulotomy (P=0.05).

Conclusions

The multidisciplinary approach at specialized units will lead to successful outcome in >60% of patients with Crohn’s perianal fistulas. The presence of Crohn’s colitis, young age at disease onset, and presence of high fistulas are indicators of poor prognosis.     

The efficacy of anal fistula plug in fistula‐in‐ano: a systematic review

Aims To assess the efficacy of anal fistula plug (AFP) procedure for the treatment of fistula‐in‐ano especially the complex fistulas. Method The database of PUBMED, MEDLINE, SCOPUS, EMBASE and COCHRANE LIBRARY for the period 1995–2009 was searched. A systematic analysis was carried to evaluate the success rate of AFP procedure in fistula‐in‐ano. Results A total of 25 studies were extracted and 12 (n = 317) were finally included in the systematic review. The follow‐up period ranged from 3.5 to 12 months. The AFP procedure had a success rate (patient cure rate) ranging from 24% to 92%. In complex fistula‐in‐ano in prospective studies (8/12 studies), the success rate was 35–87%. The success rate in patients with Crohn’s disease was 29–86%. The success rate in the patients with single tracts was 44–93% and in patients with multiple tracts, success ranged from 20% to 71%. The abscess formation/sepsis rate was 4–29% (11/108) and the plug extrusion rate was 4–41% (42/232–19%). Conclusion Anal fistula plug procedure has a success rate ranging from 24% to 92% in different studies. In prospective studies of complex fistula‐in‐ano, there was a moderate success rate of 35–87%. As AFP is associated with low morbidity and sepsis, it appears to be a safe procedure. Further randomized controlled trials studying objective parameters of fistula healing are needed to substantiate these findings.     

Perianal suppuration: results of treatment

Perianal suppuration (PAS) is a common surgical problem that is frequently treated inadequately. A series of 101 patients with PAS was reviewed. Thirty-six patients had a history of PAS. Fifty patients had drainage of a perianal abscess; six patients developed fistulas in ano and in two recurrent abscess developed (total, 16%). Thirty-six patients had fistulotomy for established anal fistula: three patients (8%) had recurrent fistulas. Fifteen patients had single-stage drainage of abscess and fistulotomy, and none had recurrent or residual PAS. All patients ultimately achieved healing. These results illustrate the fact that satisfactory results in the treatment of PAS can be obtained by surgeons if established principles of treatment are observed.     

Anal fistula plug in the treatment of anal fistula: Local experience in Chinese patients

Background: Anal fistula plug was recently introduced as an alternative treatment for anal fistula. However, there is, so far, no published data on the use of the anal fistula plug both locally and in the Chinese population. Methods: From January 2007 to July 2008, consecutive Chinese patients with transphincteric or suprasphincteric anal fistula scheduled for elective surgery were enrolled. Anal fistula plug was used if examination under anaesthesia reviewed an internal opening. Baseline manometry pressure study was carried out for patients with recurrent fistulae. The operative technique was standardized. Measured outcomes included healing and recurrence rates, operating time, length of stay, and time for patients to return to work or normal activity. Results: Eleven patients underwent anal fistula plug placement, with a median follow up of 19 months. Five had completely healed fistulae, including three patients with recurrent fistulae. The success rate was 45 per cent. In the three patients with recurrent fistulae, no significant difference was demonstrated in the resting pressure between preoperative and postoperative values. There is an observable trend that proportionally more recurrent fistulae were healed by anal fistulae plug placement when compared to primary fistulae (100% vs 25%); the difference, however, did not reach statistical significance (P = 0.06, Fisher's exact test). At the conclusion of this study, no recurrence was noted in the five patients with confirmed healing. Conclusions: Our preliminary experience indicates anal fistula plug placement is safe and non-invasive. However, the efficacy appears lower than initially reported. Based on our data the routine use of an anal fistula plug cannot be recommended. In our opinion, anal fistula plug placement can be considered in patients with more complex, high fistulae and in those who have recurrent fistulae despite previous surgery. It provides a non-invasive alternative in these patients, in whom postoperative incontinence is a real concern.     

Biological fibrin used in anal fistulas: 31 patients

Aim of the study. - The different treatments proposed for transsphincteric and suprasphincteric cryptoglandular anal fistulas are often complex and often associated with complications. After one or two stage anal fistulotomy, the risk of change in fecal continence ranks from 30% to 40%. This rate is lower (10%) with transanal advancement flap repair technique. A new therapeutic approach (fistula track closure by means of a fibrin sealant) that we have developed in our study allows to avoid classical sphincter dissection or section which could jeopardize normal sphincter function.Patients and methods. - Over a 20 month period, 31 consecutive patients (mean age: 42; 24 males and seven females) with transsphincteric (n = 28) or suprasphincteric (n = 3) anal fistula have been included in this study and treated with injection of a fibrin sealant into fistula track. Patients were controlled during a mean follow-up of 9 month.Results. - Fistula cure was obtained in 83.9% cases (75% after single fibrin sealant application). Success was achieved after a second application in two patients. Neither change in fecal continence nor other complication was observed during application and during follow-up period.Conclusion. - This technique is simple (100% feasibility) and is reproductible. Results are comparable with “classical” techniques. However, despite this surgical procedure which could be seen as simple, it requires a throrough methodology.     

Ligation of the intersphincteric fistula tract in low transsphincteric fistulae: a new technique to avoid fistulotomy

Aim To date fistulotomy is still the treatment of choice for patients with a transsphincteric fistula passing through the lower third of the external anal sphincter, because it is a simple, effective and safe procedure with a minimal risk of incontinence. However, data suggest that the risk of impaired continence following division of the lower third of the external anal sphincter is not insignificant, especially in female patients with an anterior fistula and patients with diminished anal sphincter function. It has been shown that ligation of the intersphincteric fistula tract (LIFT) is a promising sphincter‐preserving technique. Therefore, we questioned whether LIFT could replace fistulotomy in patients with a low transsphincteric fistula. Method A consecutive series of 22 patients with a low transsphincteric fistula of cryptoglandular origin underwent LIFT. Continence scores were determined using the Rockwood Fecal Incontinence Severity Index. Results Median follow‐up was 19.5 months. Primary healing was observed in 18 (82%) patients. In the four patients without primary healing, the transsphincteric fistula was converted into an intersphincteric fistula. These patients underwent subsequent fistulotomy with preservation of the external anal sphincter. The overall healing rate was 100%. Six months after surgery, the median incontinence score was not changed significantly. Conclusion Low transsphincteric fistulae can be treated successfully by LIFT, without affecting faecal continence. Division of the lower part of the external anal sphincter is no longer necessary in the treatment of low transsphincteric fistulae, which is essential for patients with compromised anal sphincters.     

Efficacy of the anal fistula plug in complex anorectal fistulae

Objective  The treatment of complex anorectal and rectovaginal fistulae remains a difficult problem. The options are fistulotomy, setons, fibrin glue and a variety of flap procedures. Recently, there have been several reports of a new plug; the Surgisis® AFP™ plug. Reports from various centres do not give consistent results. The aim of this study was to assess the efficacy of the Surgisis® AFP™ fistula plug in a wide spectrum of patients with anorectal, rectovaginal and pouch vaginal fistulae.
Method  Between March 2006 and September 2007, patients with a variety of anal fistulae were selected for fistula plug insertion in the coloproctology units at Leeds, UK, and Aarhus, Denmark. Demographic and fistulae details were obtained. Postoperatively, all patients had a course of oral antibiotics.
Results  Forty-three patients with a median age of 45 (range 18–65) years underwent a total of 45 procedures. Seventy-five per cent ( n  =   32) had a fistula secondary to cryptoglandular abscess. Median follow up was 47 (range 12–77) weeks. The success rate for complete healing was 44%. Dislodgement caused failure on 10 (22%) occasions.
Conclusion  Our study shows a moderate success rate for treatment with fistula plugs. The complex nature of the fistulae selected may be the reason for the low success rate.     

PERFACT procedure to treat supralevator fistula-in-ano: A novel single stage sphincter sparing procedure

AIM: To prospectively perform the PERFACT procedure in supralevator anal fistula/abscess.METHODS: Magnetic resonance imaging was done preoperatively in all the patients. Proximal cauterization around the internal opening, emptying regularly of fistula tracts and curettage of tracts(PERFACT) was done in all patients with supralevator fistula or abscess. All types of anal fistula and/or abscess with supralevator extension, whether intersphincteric or transsphincteric, were included in the study. The internal opening along with the adjacent mucosa was electrocauterized. The resulting wound was left open to heal by secondary intention so as to heal(close) the internal opening by granulation tissue. The supralevator tract/abscess was drained and thoroughly curetted. It was regularly cleaned and kept empty in the postoperative period. The primary outcome parameter was complete fistula healing. The secondary outcome parameters were return to work and change in incontinence scores(Vaizey objective scoring system) assessed preoperatively and at 3 mo after surgery.RESULTS: Seventeen patients were prospectively enrolled and followed for a median of 13 mo(range 5-21 mo). Mean age was 41.1 ± 13.4 years, M:F-15:2. Fourteen(82.4%) had a recurrent fistula, 8(47.1%) had an associated abscess, 14(82.4%) had multiple tracts and 5(29.4%) had horseshoe fistulae. Infralevator part of fistula was intersphincteric in 4 and transsphincteric in 13 patients. Two patients were excluded. Eleven out of fifteen(73.3%) were cured and 26.7%(4/15) had a recurrence. Two patients with recurrence were reoperated on with the same procedure and one was cured. Thus, the overall healing rate was 80%(12/15). All the patients could resume normal work within 48 h of surgery. There was no deterioration in incontinence scores(Vaizey objective scoring system). This is the largest series of supralevator fistula-in-ano(SLF) published to date. CONCLUSION: PERFACT procedure is an effective single step sphincter saving procedure to treat SLF with minimal risk of incontinence.