D Other Techniques

Recent innovative therapy involves the use of adhesive products. Several studies have reported on fibrin glue treatment of anal fistula using both autologous fibrin tissue adhesives and commercially available fibrin glue. The adhesive is instilled in the fistula tract after curetting, and sometimes irrigation of the tract, to allow glue adhesion to the tissue. Insertion of the fibrin glue is continued until glue appears at the internal opening of the fistula. The sealant not only acts as a closing plug for the fistula, but also as the substrate for the in-growth of fibroblasts. The technique is not suitable for fistulas with extensions.

The reported success rates in patients have varied from 40% to 85%, with a mean of 67% for the various materials. Recently Buchanan and colleagues reported long-term healing of only 14%, whereas Sentovich showed a healing rate of 60% when all patients had a draining seton preoperatively and the internal opening was closed with a suture at the time of glue instillation. In a later review by Swinscoe and colleagues of 12 studies, the overall healing rate was 53%. However, in patients with Crohn disease, fistula results have been considerably lower. The use of human granulocyte colony-stimulating factor instead of fibrin glue has been shown to heal perianal Crohn-associated fistula in some patients.

Johnson and colleagues recently introduced a new method of closure for anal fistula with a bioprosthetic plug. The conically shaped plug, made of porcine collagen, is pulled into the primary tract through the internal opening until it fills out the whole length of the tract. Both ends of the plug are secured with sutures and at the internal opening, the end of the plug is covered with mucosa and also preferably with internal sphincter. The remaining external opening is left open for drainage. Champagne and colleagues reported a success rate of 83% with a median follow-up of 12 months for high cryptoglandular anal fistulas, and the method has also been used in a smaller group of patients with Crohn fistulas reported by O’Connor and colleagues. However the exact place that these modalities have in the management of Crohn fistula remains unclear, and their use does not preclude surgical procedures should the treatment fail.

Asymptomatic fissures, hemorrhoids, and skin tags in Crohn patients should be left alone and if surgery is requested, the patient should be informed of complications such as poor healing, stenosis, incontinence, and ulcer formation. Anal ulcers are likely to be worsened by surgery, and a trial with medical therapy should be instituted to promote healing. In refractory symptomatic anal fissures without proctitis, lateral sphincterotomy is indicated. Symptomatic strictures should be cautiously dilated with Hegar dilators or an endoscopic balloon, as perforation is a risk. The stricture may be primary or occur as a complication of anorectal or ileal pouch surgery performed on the basis of an incorrect preoperative diagnosis of ulcerative colitis or indeterminate colitis. Severe strictures that do not respond to dilation may require an advancement flap (in low anal strictures) or ultimately fecal diversion or proctectomy (in anorectal stenosis).

Given the unpredictable disease process of perianal Crohn fistulas and the variety of surgical options, management should be individually tailored, using a combined medical and surgical approaches to offer the patient an improved quality of life.

Buchanan GN, Bartram CI, Phillips RK, et al. Efficacy of fibrin sealant in the management of complex anal fistula: a prospective trial. Dis Colon Rectum. 2003;46:1167-1174. [PMID: 12972959] Champagne BJ, O’Connor LM, Ferguson M, et al. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long term followup. Dis Colon Rectum. 2006;49:1817-1821. [PMID: 17082891] Cintron JR, Park JJ, Orsay CP, et al. Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up. Dis Colon Rectum. 2000;43:944-949. [PMID: 10910240]

Johnson EK, Gaw JU, Armstrong DN. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum. 2006;49:371-376. [PMID: 16421664]

Lindsey I, Smilgin-Humphreys MM, Cunningham C, et al. A randomized, controlled trial of fibrin glue vs. conventional treatment for anal fistula. Dis Colon Rectum. 2002;45:1608-1615. [PMID: 12473883]

Loungnarath R, Dietz DW, Mutch MG, et al. Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum. 2004;47:432-436. [PMID: 14978618]

O’Connor L, Champagne BJ, Ferguson MA, et al. Efficacy of anal fistula plug in closure of Crohn’s anorectal fistulas. Dis Colon Rectum. 2006;49:1569-1573. [PMID: 16998638]

Sentovich SM. Fibrin glue for anal fistulas: long-term results. Dis Colon Rectum. 2003;46:498-502. [PMID: 12682544]

Swinscoe MT, Ventakasubramaniam AK, Jayne DG. Fibrin glue for fistula-in-ano: the evidence reviewed. Tech Coloproctol. 2005;9:89-94. [PMID: 16007368]

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