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.     

Plugs unplugged. Anal fistula plug: the Concord experience

Purpose: The purpose of this study was to analyse preliminary experience and outcomes with the Cook Surgisis AFP? anal fistula plug (Cook Medical, Bloomington, IN, USA) with respect to the treatment of complex anal fistulae in a specialist colorectal unit. Methods: Data on all patients who were treated with the Surgisis AFP? between October 2006 and January 2009 were retrospectively reviewed. The plug was placed in accordance with the Cook guidelines. Successful closure of the anal fistula was defined as absence of drainage at final follow‐up with no subsequent abscess formation or further intervention required. Results: Thirty‐two patients underwent a total of 35 anal fistula plug insertion procedures. No patients were lost to follow‐up. The median follow‐up was 15 months (2–29 months). The overall success rate was 13 out of 35 (37%). For those in the subgroups of Crohn's disease and cryptoglandular disease, the success rate was 1 out of 3 (33%) and 11 out of 31 (35%), respectively. Conclusion: This series demonstrates a success rate for the Cook Surgisis AFP? of 37%. These results in patients managed in a specialist unit confirm that the Surgisis AFP? is a useful option in the management of complex fistulae.     

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.     

Anal fistula plug vs mucosa advancement flap in complex fistula-in-ano: A meta-analysis

AIM: To investigate the efficacy of the anal fistula plug (AFP) compared to the mucosa advancement flap (MAF), considered the best procedure for patients with a complex anal fistula.METHODS: The literature search included PubMed, EMBASE, Cochrane Library and OVID original studies on the topic of AFP compared to MAF for complex fistula-in-ano that had a deadline for publication by April 2011. Randomized controlled trials, controlled clinical trials and prospective cohort studies were included in the review. After information collection, a meta-analysis was performed using data on overall success rates as well as incidence of incontinence and morbidity. The quality of postoperative life was also included with the clinical results.RESULTS: Six studies involving 408 patients (AFP = 167, MAF = 241) were included in the meta-analysis. The differences in the overall success rates and incidence of fistula recurrence were not statistically significant between the AFP and MAF [risk difference (RD) = -0.12, 95%CI: -0.39 - 0.14; RD = 0.13; 95%CI: -0.18 - 0.43, respectively]. However, for the AFP, the risk of postoperative impaired continence was lower (RD = -0.08, 95%CI: -0.15 - -0.02) as was the incidence of other complications (RD = -0.06, 95%CI: -0.11 - -0.00). The postoperative quality of life, for patients treated using the AFP was superior to that of the MAF patients. Patients treated with the AFP had less persistent pain of a shorter duration and the healing time of the fistula and hospital stay were also reduced.CONCLUSION: The AFP is an effective procedure for patients with a complex anal fistula; it has the same success rate but a lower risk of complications than the MAF and may also be associated with an improved postoperative quality of life. Additional evidence is needed to confirm these findings.     

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.     

To determine the efficacy of anal fistula plug in the treatment of high fistula-in-ano: an initial experience

Objective  The aim of this study was to determine the efficacy of the anal fistula plug in the treatment of high fistula-in-ano.
Method  Twenty-three patients with high cryptoglandular fistula-in-ano were prospectively studied over 1 year. The number of tracks, number of previous procedures and co-morbid conditions that could potentially affect outcome were noted. A seton was used to guide the AFP™ into the fistula track which was anchored at the primary opening.
Results  Two patients were lost to follow-up. Twenty-one patients (mean age was 49.8 years) were followed from 192 to 543 days (median = 292 days). Thirteen patients had single track, eight had multiple tracks and 14 had a recurrent fistula. Success, defined by closure of all fistula tracks occurred in 71.4% (15/21). The success rate was 84.6% in patients with a single fistula track (11/13) compared with 50% in patients with multiple tracks (4/8) ( P  = 0.14, Fisher's exact test). Recurrent [10/14 (71.4%)] vs nonrecurrent fistulae [5/7 (71.4%)] had no bearing on the outcome ( P  = 1.0). Two patients experienced healing despite extrusion of the plug in the early postoperative period. The procedure was safe and well tolerated.
Conclusion  The Surgisis® AFP™ was successful in 71.4% of patients. Plug extrusion does not necessarily mean failure.     

A treatment protocol for chronic post-pneumonectomy empyema associated with bronchopleural fistula: A single-centre retrospective study

Chronic post-pneumonectomy empyema (CPPE) associated with bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. This study aims to propose a treatment protocol for managing this severe disease. From July 2009 to June 2021, 47 CPPE with BPF patients were treated in our department. CT scan with 3D reconstruction was used to detect BPF and to evaluate the location and volume of empyema cavity. Different surgical techniques were used to close BPFs according to they sizes. Multiple pedicled muscle flaps were chosen to fill the empyema cavity, and among them, latissimus dorsi (LD) was the mostly used flap. For cases that regional flaps were not suitable, free flaps were used. Patients were followed-up from 7.9 to 102.8 months. Forty-four patients (93.6%) healed after the operation. Closure of BPFs failed in three patients (6.4%), leading to regional infection. These patients were treated by bronchoscopic application of sealants, continuous drainage and antibiotics, and they eventually healed. Total or partial flap loss was not seen in any of the cases. Treatment protocol was proposed based on these results. CT scan with 3D reconstruction is an effective examination to evaluate pleural cavity defect and BPF. Proper technique to close the BPF and right choice of flap to fulfil the empyema cavity are the two most important key points to treat CPPE associated with BPF patients.     

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.     

Multidimensional long-term outcome analysis after single-level lumbar microdiscectomy: a retrospective single-centre study

Objective

To present multidimensional long-term results after mono-segmental microdiscectomy for lumbar disc herniation (LDH) in a large adult cohort treated at a tertiary care centre.

Methods

Retrospective study design with Oswestry Disability Index (ODI) questionnaire employed at follow-up. All patients undergoing surgical treatment for single-level LDH between 2003 and 2009 were identified. Electronic patient records and imaging data were analysed.

Results

A total of 939 patients underwent single-level lumbar MD at our institution. Three hundred and seven complete ODI forms (32.7%) were returned at a median follow-up of 48 months. Mean ODI score was 24.04, and mean age was 58 years. Females reported slightly higher ODI scores (25.52 vs. 22.68). Age and ODI score showed statistically significant correlation. Early surgery yielded lower ODI scores with patients faring significantly worse if symptoms persisted for a year or longer (one-way ANOVA, p < 0.001). ODI scores increased sharply even among those operated later than 1 week after symptom onset. Sequestered herniations were associated with significantly lower ODI scores than contained discs on MRI (21.96 vs. 39.89). Surgical complications occurred in 17 cases (5.6%), 82 patients (26.7%) required additional surgery, 58 (18.9%) of those for recurrent disc herniations.

Conclusion

Our findings suggest better outcomes with early surgical treatments. Time limits for conservative treatments should be set to avoid the chronification of pain and the worse overall outcomes that go along with belated surgery. Particularly in those with acute onset of pain, sequestered herniations and only mild degrees of immobilization good outcomes are common and surgical treatment appears best if indicated early.

     

Gore Bio‐A® Fistula Plug: a new sphincter‐sparing procedure for complex anal fistula

Aim The surgical treatment of a complex anal fistula remains controversial, although ‘sphincter‐saving’ operations are desirable. The Gore Bio‐A^® Fistula Plug is a new bioprosthetic plug that has been proposed for the treatment of complex anal fistula. This study reports preliminary data following implantation of this plug. Method Eleven patients with a complex anal fistula underwent insertion of Gore Bio‐A^® Fistula Plugs. The disc diameter and number of tubes in the plug were adapted to the fistula to allow accommodation of the disc into a submucosal pocket, and the excess tubes were trimmed. During the follow‐up period, patients underwent clinical and physical examinations and three‐dimensional endoanal ultrasound. Results Fistulas were high anterior transphincteric in five patients and high posterior transphincteric in six patients. All patients had a loose seton placement before plug insertion. Two, three and four tubes were inserted into the fistula plug in seven, three and one patient, respectively. The median follow‐up period was 5 months. No patient reported any faecal incontinence. There was no case of early plug dislodgement. Treatment success was noted for eight (72.7%) of 11 patients at the last follow‐up appointment. Conclusion Implanting a Gore Bio‐A^® Fistula Plug is a simple, minimally invasive, safe and potentially effective procedure to treat complex anal fistula. Patient selection is fundamental for success.     

Novel biological strategies in the management of anal fistula

Background The mostly widely studied biomaterials for the sphincter sparing treatment of anal fistulas are fibrin glue and the anal fistula plug (AFP). However their overall mean clinical success is only 50–60%. As the understanding of the pathology of anal fistula, wound healing and the host response to materials has improved, so new biological sphincter‐sparing strategies have been developed. The aim of this review is to assess the safety and efficacy of these novel techniques. Method PubMed, the Cochrane database and EMBASE were independently searched. All studies that investigated the potential of a biomaterial (defined as any synthetic or biologically derived substance in contact with host tissue) to augment the healing of anal fistula without sphincter division were included. Studies solely describing the role of fibrin glue or an AFP were excluded. Data extraction included type of material, fistula aetiology, treatment of the primary tract, fistula healing, incontinence, duration of follow‐up and any specific complications. Systematic quality assessment of the included articles was performed. Results Twenty‐three articles were finally selected for review. These included a variety of biological and synthetic systems that were employed to deliver selected components of the extracellular matrix, growth factors, cytokines, stem cells or drugs to the fistula tract. Conclusion To date no study matches fistulotomy with regard to long‐term fistula eradication rate. This is probably due to implant extrusion, inadequate track preparation or an unsuitable material. Future techniques need to address all these issues to ensure success. Success should be validated by MRI or long‐term follow‐up.