Abstract
Purpose
Perianal fistulas, and specifically high perianal fistulas, remain a surgical treatment challenge. Many techniques have, and still are, being developed to improve outcome after surgery. A systematic review and meta-analysis was performed for surgical treatments for high cryptoglandular perianal fistulas.
Methods
Medline (Pubmed, Ovid), Embase and The Cochrane Library databases were searched for relevant randomized controlled trials on surgical treatments for high cryptoglandular perianal fistulas. Two independent reviewers selected articles for inclusion based on title, abstract and outcomes described. The main outcome measurement was the recurrence/healing rate. Secondary outcomes were continence status, quality of life and complications.
Results
The number of randomized trials available was low. Fourteen studies could be included in the review. A meta-analysis could only be performed for the mucosa advancement flap versus the fistula plug, and did not show a result in favour of either technique in recurrence or complication rate. The mucosa advancement flap was the most investigated technique, but did not show an advantage over any other technique. Other techniques identified in randomized studies were seton treatment, medicated seton treatment, fibrin glue, autologous stem cells, island flap anoplasty, rectal wall advancement flap, ligation of intersphincteric fistula tract, sphincter reconstruction, sphincter-preserving seton and techniques combined with antibiotics. None of these techniques seem superior to each other.
Conclusions
The best surgical treatment for high cryptoglandular perianal fistulas could not be identified. More randomized controlled trials are needed to find the best treatment. The mucosa advancement flap is the most investigated technique available.
Similar content being viewed by others
References
Sainio P (1984) Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol 73(4):219–224
Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63(1):1–12
Cariati A (2013) Fistulotomy or seton in anal fistula: a decisional algorithm. Updates Surg 65(3):201–205. doi:10.1007/s13304-013-0216-1
van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG (2006) Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas: recurrent perianal fistulas: failure of treatment or recurrent patient disease? Int J Colorectal Dis 21(8):784–790. doi:10.1007/s00384-005-0072-7
van Koperen PJ, Wind J, Bemelman WA, Bakx R, Reitsma JB, Slors JF (2008) Long-term functional outcome and risk factors for recurrence after surgical treatment for low and high perianal fistulas of cryptoglandular origin. Dis Colon Rectum 51(10):1475–1481. doi:10.1007/s10350-008-9354-9
Dubsky PC, Stift A, Friedl J, Teleky B, Herbst F (2008) Endorectal advancement flaps in the treatment of high anal fistula of cryptoglandular origin: full-thickness vs. mucosal-rectum flaps. Dis Colon Rectum 51(6):852–857. doi:10.1007/s10350-008-9242-3
Soltani A, Kaiser AM (2010) Endorectal advancement flap for cryptoglandular or Crohn’s fistula-in-ano. Dis Colon Rectum 53(4):486–495. doi:10.1007/DCR.0b013e3181ce8b01
Jarrar A, Church J (2011) Advancement flap repair: a good option for complex anorectal fistulas. Dis Colon Rectum 54(12):1537–1541. doi:10.1097/DCR.0b013e31822d7ddd
Hjortrup A, Moesgaard F, Kjaergard J (1991) Fibrin adhesive in the treatment of perineal fistulas. Dis Colon Rectum 34(9):752–754
Abel ME, Chiu YS, Russell TR, Volpe PA (1993) Autologous fibrin glue in the treatment of rectovaginal and complex fistulas. Dis Colon Rectum 36(5):447–449
Johnson EK, Gaw JU, Armstrong DN (2006) Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum 49(3):371–376. doi:10.1007/s10350-005-0288-1
Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K (2007) Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract. J Med Assoc Thai 90(3):581–586
Liu WY, Aboulian A, Kaji AH, Kumar RR (2013) Long-term results of ligation of intersphincteric fistula tract (LIFT) for fistula-in-Ano. Dis Colon Rectum 56(3):343–347. doi:10.1097/DCR.0b013e318278164c
Garcia-Olmo D, Herreros D, Pascual I, Pascual JA, Del-Valle E, Zorrilla J, De-La-Quintana P, Garcia-Arranz M, Pascual M (2009) Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial. Dis Colon Rectum 52(1):79–86. doi:10.1007/DCR.0b013e3181973487
Meinero P, Mori L (2011) Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol 15(4):417–422. doi:10.1007/s10151-011-0769-2
Wilhelm A (2011) A new technique for sphincter-preserving anal fistula repair using a novel radial emitting laser probe. Tech Coloproctol 15(4):445–449. doi:10.1007/s10151-011-0726-0
Gottgens KW, Vening W, van der Hagen SJ, van Gemert WG, Smeets RR, Stassen LP, Baeten CG, Breukink SO (2014) Long-term results of mucosal advancement flap combined with platelet-rich plasma for high cryptoglandular perianal fistulas. Dis Colon Rectum 57(2):223–227. doi:10.1097/DCR.0000000000000023
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62(10):e1–34. doi:10.1016/j.jclinepi.2009.06.006
Ortiz H, Marzo J, Ciga MA, Oteiza F, Armendariz P, de Miguel M (2009) Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano. Br J Surg 96(6):608–612. doi:10.1002/bjs.6613
Ab-b-k-r MM, Wen H, Huang HG, Chu H, Lu M, Chang ZS, Ai EH, Fan K (2010) Randomized controlled trial of minimally invasive surgery using acellular dermal matrix for complex anorectal fistula. World J Gastroenterol 16(26):3279–3286
van Koperen PJ, Bemelman WA, Gerhards MF, Janssen LW, van Tets WF, van Dalsen AD, Slors JF (2011) The anal fistula plug treatment compared with the mucosal advancement flap for cryptoglandular high transsphincteric perianal fistula: a double-blinded multicenter randomized trial. Dis Colon Rectum 54(4):387–393. doi:10.1007/DCR.0b013e318206043e
Altomare DF, Greco VJ, Tricomi N, Arcana F, Mancini S, Rinaldi M, d'Urso Pulvirenti A, La Torre F (2011) Seton or glue for trans-sphincteric anal fistulae: a prospective randomized crossover clinical trial. Colorectal Dis 13(1):82–86. doi:10.1111/j.1463-1318.2009.02056.x
Ellis CN, Clark S (2006) Fibrin glue as an adjunct to flap repair of anal fistulas: a randomized, controlled study. Dis Colon Rectum 49(11):1736–1740. doi:10.1007/s10350-006-0718-8
Gustafsson UM, Graf W (2006) Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula. Br J Surg 93(10):1202–1207. doi:10.1002/bjs.5398
Herreros MD, Garcia-Arranz M, Guadalajara H, De-La-Quintana P, Garcia-Olmo D, Group FC (2012) Autologous expanded adipose-derived stem cells for the treatment of complex cryptoglandular perianal fistulas: a phase III randomized clinical trial (FATT 1: fistula advanced therapy trial 1) and long-term evaluation. Dis Colon Rectum 55(7):762–772. doi:10.1097/DCR.0b013e318255364a
Ho KS, Ho YH (2005) Controlled, randomized trial of island flap anoplasty for treatment of trans-sphincteric fistula-in-ano: early results. Tech Coloproctol 9(2):166–168. doi:10.1007/s10151-005-0220-7
Research ICoM (1991) Multicentric randomized controlled clinical trial of Kshaarasootra (Ayurvedic medicated thread) in the management of fistula-in-ano. Indian Council of Medical Research. Indian J Med Res 94:177–185
Khafagy W, Omar W, El Nakeeb A, Fouda E, Yousef M, Farid M (2010) Treatment of anal fistulas by partial rectal wall advancement flap or mucosal advancement flap: a prospective randomized study. Int J Surg 8(4):321–325. doi:10.1016/j.ijsu.2010.03.009
Mushaya C, Bartlett L, Schulze B, Ho YH (2012) Ligation of intersphincteric fistula tract compared with advancement flap for complex anorectal fistulas requiring initial seton drainage. Am J Surg 204(3):283–289. doi:10.1016/j.amjsurg.2011.10.025
Perez F, Arroyo A, Serrano P, Sanchez A, Candela F, Perez MT, Calpena R (2006) Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano. Am J Surg 192(1):34–40. doi:10.1016/j.amjsurg.2006.01.028
Singer M, Cintron J, Nelson R, Orsay C, Bastawrous A, Pearl R, Sone J, Abcarian H (2005) Treatment of fistulas-in-ano with fibrin sealant in combination with intra-adhesive antibiotics and/or surgical closure of the internal fistula opening. Dis Colon Rectum 48(4):799–808. doi:10.1007/s10350-004-0898-z
Zbar AP, Ramesh J, Beer-Gabel M, Salazar R, Pescatori M (2003) Conventional cutting vs. internal anal sphincter-preserving seton for high trans-sphincteric fistula: a prospective randomized manometric and clinical trial. Tech Coloproctol 7(2):89–94. doi:10.1007/s10151-003-0016-6
O'Riordan JM, Datta I, Johnston C, Baxter NN (2012) A systematic review of the anal fistula plug for patients with Crohn’s and non-Crohn's related fistula-in-ano. Dis Colon Rectum 55(3):351–358. doi:10.1097/DCR.0b013e318239d1e4
Jacob TJ, Perakath B, Keighley MR (2010) Surgical intervention for anorectal fistula. Cochrane Database Syst Rev 12(5):CD006319. doi:10.1002/14651858.CD006319.pub2
Hong KD, Kang S, Kalaskar S, Wexner SD (2014) Ligation of intersphincteric fistula tract (LIFT) to treat anal fistula: systematic review and meta-analysis. Tech Coloproctol. doi:10.1007/s10151-014-1183-3
Cirocchi R, Trastulli S, Morelli U, Desiderio J, Boselli C, Parisi A, Noya G (2013) The treatment of anal fistulas with biologically derived products: is innovation better than conventional surgical treatment? An update. Tech Coloproctol 17(3):259–273. doi:10.1007/s10151-012-0948-9
Subhas G, Singh Bhullar J, Al-Omari A, Unawane A, Mittal VK, Pearlman R (2012) Setons in the treatment of anal fistula: review of variations in materials and techniques. Dig Surg 29(4):292–300. doi:10.1159/000342398
Acknowledgments
The authors thank Paul J.H. Göttgens for designing the figures showing the operative techniques.
Conflicts of interest and sources of funding
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Göttgens, K.W.A., Smeets, R.R., Stassen, L.P.S. et al. Systematic review and meta-analysis of surgical interventions for high cryptoglandular perianal fistula. Int J Colorectal Dis 30, 583–593 (2015). https://doi.org/10.1007/s00384-014-2091-8
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-014-2091-8