The status of sphincter-sparing surgery for anal fistulas
Steven D Wexner MD PhD(Hon)
Surgeon, Educator, Researcher, Author, Innovator, and Communications Leader; Past Vice Chair, Board of Regents at American College of Surgeons; Chair National Accreditation Program for Rectal Cancer
Anal fistulas are an extremely vexing problem for both the patient and the surgeon. They are often recalcitrant, recurrent, and therefore difficult to treat. Perhaps the plethora of available surgical options is attestation to the frustration and difficulty with healing. A variety of procedures including fibrin glue, anal fistula plugs, advancement flaps, and LIFT procedures are now utilized to try to encourage fistulas to heal. In order to compare the results of these techniques Sugrue and coworkers assessed 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015. Although 70 patients were lost to follow-up the authors were able to identify an overall 44% rate of healing at a median follow-up of 9 (1- 125) months and a medium time to fistula recurrence of 3 (0 – 75) months. The authors found that by six months they were able to identify 79% of the recurrences and by 12 months 91% of the recurrences. Certain highlights of the study included that patients treated with either a rectal advancement flap, a dermal advancement flap, or a LIFT procedure were less likely to recur and patients treated with a plug or glue. Although this study did not offer any new information, it definitely made available to surgeons who treat fistulas a large long-term study supporting the superiority of the more invasive techniques of flaps and LIFTS as compared to the more innocuous ones of fibrin glue and anal plugs.
General, Laparoscopic, GI and Bariatric Surgeon M.B.B.S, DNB (General Surgery), FMAS, FIAGES, DipMAS (Bariatric Surgery), DNB (Gen Surg) Teaching Faculty
5 年Why only few procedures are being compared. Fistula management has a lot more, and although with a very limited experience which I have, age old fistulotomy is still an useful option!
Head 1st General Surgery Department Iaso Thessalias- Larissa Greece
5 年You dont ever consider Vaaft, Filac, Or hybrid procedures like Vaaft plus mucosal flap advancement, of Vaaft plus Filac....
Colorectal Surgeon at Elisabeth-TweeSteden Ziekenhuis (ETZ)
5 年I was puzzled by this study. Interestingly, the authors evidently yield beter results using Flap Repairs than by using any other techniques, yet this technique is utilised less as time progresses. I think this is an indication that Flap Repair is considered either (too) complex or (too) damaging. I reiterate that Flap Repair should be considered gold standard for complex fistulas. Moreover, some hesitancy in applying new techniques would not be a bad thing in our profession, especially concerning fistula surgery.