C. Neal Ellis

Fibrin Glue as an Adjunct to Flap Repair of Anal Fistulas: A Randomized, Controlled Study

PurposeBoth flap repair and fibrin glue are accepted sphincter-preserving techniques for managing anal fistulas. Additionally, the two techniques are not mutually exclusive and can be combined. This trial was undertaken to determine whether the combination of flap repair and fibrin glue resulted in better outcomes than flap repair alone.MethodsBetween July 2000 and March 2004, patients with transsphincteric anal fistulas were randomly assigned to advancement flap repair alone or flap repair combined with fibrin glue obliteration of the fistula tract. Data regarding age, gender, fistula anatomy, race, and previous repairs were collected. Fistulas managed by fistulotomy or caused by Crohn’s disease, acute obstetric trauma, or radiation were excluded from this study.ResultsThere were 58 patients randomized to flap repair alone or flap repair with fibrin glue (47 males; median age, 47 (range, 29–68) years). Mucosal advancement flap was performed in 36 patients and anodermal advancement flap was performed in 22. The median follow-up was 22 (range, 12–36) months. Total fistula recurrence rate for all patients was 32.6 percent. The recurrence rate for fistulas repaired by advancement flap alone was 20 percent, whereas the recurrence rate for fistulas repaired by advancement flap with fibrin glue was 46.4 percent (P < ;0.05).ConclusionsThe data fail to show improved outcomes when fibrin sealant is used in combination with an advancement flap compared with advancement flap alone for the management of complex anal fistulas.

Outcomes With the Use of Bioprosthetic Grafts to Reinforce the Ligation of the Intersphincteric Fistula Tract (BioLIFT Procedure) for the Management of Complex Anal Fistulas

PURPOSE This study was undertaken to determine the outcomes of patients whose complex anal fistulas were managed by ligation of the intersphincteric fistula tract reinforced with a bioprosthetic graft (BioLIFT procedure). METHODS A retrospective analysis was performed of all patients whose anal fistula was managed by use of the BioLIFT technique between May 2005 and May 2008, who had a minimum of 1 year of follow-up after their last treatment. RESULTS The BioLIFT technique using a bioprosthetic graft was used to treat a complex anal fistula in 31 patients (22 men, 9 women; mean age, 48 y (range, 30-68 y). Clinical healing of the fistula, defined as the absence of drainage with no evidence of residual fistula tract, occurred in 29 (94%) patients. No complications occurred that required intervention. CONCLUSIONS The BioLIFT procedure is effective for the management of complex fistulas-in-ano. Randomized clinical trials comparing this technique with other sphincter-preserving methods for fistula management need to be performed to further determine the role of this technique in the management of anal fistulas.

Long-term outcomes with the use of bioprosthetic plugs for the management of complex anal fistulas.

PURPOSE: This study was undertaken to determine the long-term outcomes of patients whose anal fistulas were managed by use of bioprosthetic plugs. METHOD: A retrospective analysis was performed of all patients whose anal fistula was managed by use of a bioprosthetic plug between May 2005 and September 2006, who had a minimum of 1 year of follow-up since their last treatment. Patients whose fistulas were clinically healed were offered MRI to confirm healing of the fistula. RESULTS: The bioprosthetic fistula plug was used to treat an anal fistula in 63 patients with clinical healing of the fistula in 51 (81%). Multivariate analysis showed that tobacco smoking, posterior fistula, and history of previous failure of the bioprosthetic plug was predictive of failure of the bioprosthetic plug. Eight patients with clinical healing after a minimum of 1 year since their last treatment underwent MRI. No evidence of residual fistula tract or fluid in the area of the previous fistula was found in 6 (75%) of these patients. CONCLUSION: Bioprosthetic plugs are effective for the long-term closure of complex fistulas-in-ano. Randomized clinical trials comparing bioprosthetic plugs with other sphincter-preserving methods for fistula management need to be conducted to further determine the role of bioprosthetics in the management of anal fistulas.

The surgisis® AFP™ anal fistula plug: Report of a consensus conference

A Consensus Conference was held in Chicago on 27th May 2007 at the Illinois Airport Hilton Hotel to develop uniformity of opinion from surgeons with considerable experience in the use of the Anal Fistula Plug. Of the 15 surgeons in attendance, five had performed 50 or more Anal Fistula Plug procedures. Success rates with this approach have been reported to be as high as 85% [1]. Anecdotal communications have however suggested lower rates of success. Concerns have been expressed over plug extrusion and inadequacy of long-term followup. It was thought prudent to hold this conference because, despite a number of publications attesting to the safety and efficacy of the procedure, to date there has not been uniformity of opinion regarding indications and technique, nor has there been level I evidence of any actual benefit.

Outcomes after repair of rectovaginal fistulas using bioprosthetics.

PurposeThe purpose of this study was to report the outcomes with the use of advancement flaps and bioprosthetic grafts for the management of rectovaginal fistulas.MethodsA retrospective analysis of prospectively collected data was performed for all patients treated with a rectovaginal fistula.ResultsThere were 44 patients in the advancement flap group. A mucosal flap repair was performed for 29 patients, and 15 patients had an anodermal flap repair. The mean follow-up was 10 (range, 6–22) months. There were 34 patients in the bioprosthetic repair group. A bioprosthetic interposition graft was used to repair the fistula in 27 patients with a mean follow-up of 12 (range, 6–22) months, and 7 patients had a bioprosthetic plug repair of their fistula with a mean follow-up of 6 (range, 3–12) months. The fistula recurred in 15 patients (34 percent) who were managed by a flap repair, 5 patients (19 percent) who were managed by a bioprosthetic sheet, and 1 patient (14 percent) who was treated with a bioprosthetic plug.ConclusionsUse of bioprosthetics for the management of rectovaginal fistulas is a new technique, which, based on early experience, seems to yield results equal to advancement flap repair.

Sphincter-preserving fistula management: what patients want.

PURPOSE: The purpose of this study was to determine how patients with anal fistulas would rank clinical scenarios describing various management options for anal fistulas. METHOD: A survey was administered to 74 consecutive patients with anal fistulas. On each survey, 10 clinical scenarios describing various treatment options for anal fistulas were scored from 1 (most likely to select) to 10 (least likely to select). Mean scores for each scenario were calculated and compared by use of a Student t test. RESULTS: When combined, 74% of patients selected a sphincter-preserving technique as their primary choice compared with 26% who chose a fistulotomy (P < .0001). Compared with the highest ranking sphincter-preserving techniques, the mean scores of the scenarios involving a fistulotomy were significantly (P < .05) lower (less likely to select). The mean score of a traditional fistulotomy was the same as the mean score of a sphincter-preserving technique with a 50% success rate but no risk of diminished continence. CONCLUSIONS: These data suggest that the majority of patients with an anal fistula will select a sphincter-preserving technique to manage their fistula. This finding may indicate that, within limits, it is of greater importance for most patients to minimize their risk of diminished continence than to have a highly successful treatment strategy for their fistula.

Short-term outcomes with the use of bioprosthetics for the management of parastomal hernias.

PURPOSE: This study was undertaken to determine the safety and short-term outcomes using bioprosthetics for the management of parastomal hernias. METHODS: A retrospective review of prospectively collected data for all of the patients who underwent repair of a parastomal hernia was conducted. RESULTS: Between April 2004 and September 2007, 20 consecutive patients had 22 parastomal hernias repaired through a midline incision using a bioprosthetic with the stoma entering the abdomen lateral to the graft. A colostomy was present in 17 patients; an ileostomy was present in 3 patients. All of the patients had parastomal hernia–related complications. Postoperatively there were no infections of the midline wound or the prosthetic, and none of the grafts were removed. There were 4 seromas (40%) that required aspiration in the 10 procedures performed before the routine placement of a drain. No incisional hernias have developed in the midline wound. There have been 2 (9%) recurrent parastomal hernias on physical examination at a median follow-up of 18 months (range, 12–54). CONCLUSIONS: These data suggest that bioprosthetics are safe and are effective in the short term for the repair of parastomal hernias.

Clinical significance of diminutive polyps of the rectum and sigmoid colon

A retrospective review of 637 consecutive colonoscopies with polypectomy in 526 patients was performed to determine the association of small polyps of the rectum and sigmoid colon with more proximal colonic neoplasms. All colonic polyps were proximal to the sigmoid colon in 117 procedures. Proximal neoplasms were found in 32 percent of patients with a single polyp in the rectum or sigmoid colon. The incidence increased to 83 percent for those with three or more polyps. The occurrence of proximal colonic neoplasms was not affected by the size or histologic type of the rectosigmoid polyps. These findings would suggest that total colonic evaluation be considered in all patients with a polyp in the rectum or sigmoid colon regardless of the size or histologic type of the polyp.

Stapled Transanal Rectal Resection (STARR) for Rectocele

Patients with obstructed defecation complain of an inability to initiate rectal emptying, incomplete evacuation, pelvic pressure or excessive straining at stool. The pathophysiologic features of obstructed defecation include an increased anterior-posterior diameter of the rectum, decreased rectal compliance and an increased sensory threshold volume. Recently, there has been interest in the transanal resection of the rectum for obstructed defecation with the developement of endoanal staplers and techniques specifically for these purpose. Stapled transanal rectal resection (STARR), in the only large series reported, decreased the anterior-posterior diameter of the rectum, restored rectal compliance and decreased the rectal sensory threshold with an associated improvement in incomplete evacuation in 81.1%, digital assistance to defecate in 83.4%, pelvic pain in 43.3%, and the need for laxatives 43.3% of patients. Risks of the procedure included stenosis in 3.3%, urgency in 1.1% and incontinence of flatus in 1.1% of patients. These data suggest that the STARR procedure is an effective management option for obstructed defecation with an acceptable risk of complications.

Colonic adenomatous polyposis syndromes: clinical management.

Colorectal cancer is one of the major causes of cancer deaths in both men and women. It is estimated that 5 to 10% of patients with colorectal cancer have an inherited germline mutation that predisposes them to cancer. Hereditary colorectal cancer syndromes can be divided into those associated with colonic polyposis - familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (aFAP), and MYH associated polyposis (MAP), and those not associated with colonic polyposis - hereditary nonpolyposis colon cancer (HNPCC). The hereditary polyposes are usually easier to diagnose than HNPCC, but their higher penetrance and variable phenotype pose some difficult problems in management and surveillance. The timing and type of surgical intervention, the management of desmoid risk, the treatment of rectal or pouch neoplasia, and the management of duodenal neoplasia are all questions that must be addressed in patients with FAP or MAP.