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High Anal Fistulas: Treatment-Options
Fistula in ano
Therapeutic Options in High Anal Fistulas
A. HeroldEnd- und Dickdarmzentrum Mannheim
High Anal Fistulas: Treatment-Options
subanodermalsubanodermalintersphinctericintersphincteric FistulectomieFistulectomiedistal transsphinctericdistal transsphincteric
„Standard Treatment“ of high fistulas
prox. transsphinctericsuprasphincteric Flap procedureextrasphincteric
High Anal Fistulas: Treatment-Options
Flap procedure
High Anal Fistulas: Treatment-Options
Athanasiadis S (1995): Int J Colorect Dis S. 153
Type n Persistence Recurrence
Transsph. 189 9 % 17 %
Suprasph. 35 20 % 37 %
Rectovag. 10 33 % 40 %
Recurrent f. 21 38 % 47 %
Crohn`s f. 29 28 % 48 %
Mucosal - flap: Results (1)
High Anal Fistulas: Treatment-Options
Athanasiadis S (1995): Int J Colorect Dis S. 153
Type n Persistence Recurrence Healing
Transsph. 189 9 % 17 % 74 %
Suprasph. 35 20 % 37 % 43 %
Rectovag. 10 33 % 40 % 37 %
Recurrent f. 21 38 % 47 % 15 %
Crohn`s f. 29 28 % 48 % 24 %
Mucosal - flap: Results (1)
High Anal Fistulas: Treatment-Options
Author Year n Type Rec „Incont“
Williams 91 13 mixed 0 % 62 %Garcia-Aguilar 85 151 mixed 2 % 10 %Wedell 87 30 trans 3 % 0 %Girona 87 96 trans/supra 3/8 % 8/19 %Oh 93 15 mixed 13 % -EDZ 03 41 trans 10 % 0 %Athanasiadis 94 189 trans 20 % 21 %Athanasiadis 83 81 mixed 21 % -Schouten 99 44 trans 25 % -Jones 87 39 trans 31 % -Gustafsson 02 42 trans 45 % 11 %Baeten 05 41 mixed 63 % (3Ja.) 17 %
Mucosal - flap: Results (2)
High Anal Fistulas: Treatment-Options
n = 88, 04/2001 – 04/2004, Follow up: 35 mo (18 - 60 mo), 18% recurrent, 12% horse shoe, without Crohn´s,
Transsphincteric: n = 41
Total Healing: n = 35 (85 %)
Primary Healing: n = 27 (66 %)
EDZ - Results (transsphincteric)
High Anal Fistulas: Treatment-Options
Transsphincteric: n = 41
Total Healing: n = 35 (85 %)
Primary Healing: n = 27 (66 %)
Persistence: n = 10 (24 %)
Recurrence: n = 4 (10 %)
EDZ - Results (transsphincteric)
n = 88, 04/2001 – 04/2004, Follow up: 35 mo (18 - 60 mo), 18% recurrent, 12% horse shoe, without Crohn´s,
Re-Flap healed: n = 2Fistulectomy: n = 5Excision + Reconst: n = 1Still persisting: n = 6
Total Healing Rate with Flap: 71 % (Incontinent: 0%)
High Anal Fistulas: Treatment-Options
Treatment Alternatives
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
Fistulectomy and
primary repair
Longterm – Seton
High Anal Fistulas: Treatment-Options
Anal - Fistula - Plug (AFP)
Surgisis Anal Fistula Plug
High Anal Fistulas: Treatment-Options
AFP - Procedure
High Anal Fistulas: Treatment-Options
n = 25 Pat. (transsphincteric Fistulas), kryptoglandular, FU: 13 wks.
Johnson E, Armstrong D (USA): Dis Colon Rectum 2006 S. 371
n Healing
Fibrine 10 40 %
Plug 15 87 %
AFP: First Prospective Trial
High Anal Fistulas: Treatment-Options
n = 20 Pat. (36 transsphincteric Fistulae), Crohn`s Disease, FU: 10 Mo. (3 – 24)
O`Connor L, Armstrong D (USA): Dis Colon Rectum 2006 S. 1569
n Healing
Simple Fistula 13 100 %
Komplex Fistula 7 45 %
Total 20 80 %
AFP: Prospective Trial
High Anal Fistulas: Treatment-Options
Anal Fistula Plug: Results (USA)
Author Year n FU Healing
Robb (ASCRS 2004) 04 17 12 Mo
Champagne (Armstrong) 06 46 12 Mo
Poirier (Abcarian) 06 28 3 Mo
Ky (New York) 07 42 3 Mo
Christoforidis (Mineapolis) 07 57 3 Mo
Cintron (USA) 07 28 3 Mo
Abbas (Efron LA) 07 17 7 Mo
Safar (Wexner) 07 39 4 Mo
High Anal Fistulas: Treatment-Options
Author Year n FU Healing
Robb (ASCRS 2004) 04 17 12 Mo 65 %
Champagne (Armstrong) 06 46 12 Mo 83 %
Poirier (Abcarian) 06 28 3 Mo 54 %
Ky (New York) 07 42 3 Mo 81 %
Christoforidis (Mineapolis) 07 57 3 Mo 40 %
Cintron (USA) 07 28 3 Mo 54 %
Abbas (Efron LA) 07 17 7 Mo 24 %
Safar (Wexner) 07 39 4 Mo 14 %
Anal Fistula Plug: Results (USA)
High Anal Fistulas: Treatment-Options
Anal Fistula Plug: Results (Europe)
Author Year n FU Healing
Lenisa (I) 07 27 8 Mo 85 %
Van Koperen (NL) 07 17 7 Mo 41 %
Garg (Ind) 07 27 6 Mo 66 %
Bohe (Sw) 07 32 6 Mo 66 %
Thekkinkattil (UK) 07 38 6 Mo 39 %
AFP-Workshop 07 15-25 < 6 Mo 41-70 %
High Anal Fistulas: Treatment-Options
Anal Fistula Plug: Results Germany (Follow up 6 Mo.)
Author n FU Healing
Schwandner (Gießen) 60 trans.
Soetje (Wiesbaden) 59 trans.
Scherer (Berlin) 25 Ftr/Fsu
Schwandner (Regensburg) 19 trans.
Herold (Mannheim) 18 trans
Peters (Köln) 13 trans.
Kolbus (Leipzig) 7 trans.
Pakravan (Düsseldorf) 6 trans
High Anal Fistulas: Treatment-Options
Author n FU Healing
Schwandner (Gießen) 60 trans. 63 %
Soetje (Wiesbaden) 59 trans. 74 %
Scherer (Berlin) 25 Ftr/Fsu 48 %
Schwandner (Regensburg) 19 trans. 61 %
Herold (Mannheim) 18 trans 39 %
Peters (Köln) 13 trans. 38 %
Kolbus (Leipzig) 7 trans 85 %
Pakravan (Düsseldorf) 6 trans 66 %
Anal Fistula Plug: Results Germany (Follow up 6 Mo.)
High Anal Fistulas: Treatment-Options
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
Fistulectomy and
primary repair
Longterm – Seton
Author Year n FU Healing
Abel (USA) 93 6 7 Mo 75 %
Cintron (USA) 00 53 12 Mo 72 %
Patrlj (Yug) 00 30 28 Mo 70 %
Lindsey (GB) 02 17 17 Mo 43 %
Chan (GB) 02 10 6 Mo 60 %
Sentovich (USA) 03 36 22 Mo 69 %
Zmora (USA) 03 10 12 Mo 33 %
Buchanan (GB) 03 16 14 Mo 16 %
Loungnarath (USA) 04 22 < 26 Mo 23 %
Treatment Alternatives
High Anal Fistulas: Treatment-Options
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
Fistulectomy and
primary repair
Longterm – Seton
Treatment Alternatives
High Anal Fistulas: Treatment-Options
Fistulectomy and Secondary Repair
High Anal Fistulas: Treatment-Options
Author Year n Success
Keighley (GB) 83 19 61 %Browning (GB) 84 97 78 %Fang (USA) 84 79 89 %Christiansen (DK) 87 23 60 %Laurberg (USA) 88 19 47 %Ctercteko (USA) 88 58 64 %Yoshioka (GB) 89 27 74 %Jacobs (NL) 90 37 83 %Fleshman (USA) 91 55 51 %Wexner (USA) 91 16 76 %Arnaud (F) 91 40 63 %Engel (NL) 94 55 76 %Oliveira (USA) 96 55 71 %Mölle (CH) 97 33 74 %Halverson (USA) 01 45 41 %EDZ (D) 04 32 87 %
Total: 35 Studies: Success rate 75 % (41 – 89 %)
Secondary Repair: Results
High Anal Fistulas: Treatment-Options
Treatment Alternatives
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
Fistulectomy and
primary repair
Longterm – Seton
High Anal Fistulas: Treatment-Options
Fistulectomy and Primary Repair
High Anal Fistulas: Treatment-Options
Fistulectomy and Primary Repair (2): Episioproctectomy
High Anal Fistulas: Treatment-Options
Author Year n Type Dehiscence Recurr. Incontinence
Parakash (Ind) 85 120 distal - 2,5 % -
Lux (D) 91 46 mixed 0 0% 20 % (1+2°)
Christiansen (DK) 95 14 mixed - 15 % 21% (1+2°)
Gemsenjäger (CH) 96 21 mixed 5 % 5 % 5 %
Lewis (GB) 96 32 mixed - 9,5 %
Roig (E) 99 31 mixed 4 % 10 % 24% (1+2°)
Perez (E) 05 35 mixed - 6 % 12 %
Herold (D) 05 34 mixed 8% (14%) 6 % -
Perez (E) 06 16 mixed 0 6 % (improved)
Herold (D) 06 84 mixed 5% (11%) 6 % no 3°
Primary Repair: Results
High Anal Fistulas: Treatment-Options
Primary Repair: Results correlated with involved Sphincter (1)
0
5
10
15
20
25
30
1 cm 1,5 cm 2 cm 2,5 cm 3 cm 4 cm 5 cm 6 cm
total (n=83) dehiscent (n=4) recurrent (n=7)
1 2 3
High Anal Fistulas: Treatment-Options
0
5
10
15
20
25
30
35
40
< 2 cm 2-3 cm > 3 cm
total (n=83) dehiscent (n=4) recurrent (n=7)
√2,5%
√4 %
Primary Repair: Results correlated with involved Sphincter (2)
Dehiscence: 0% - 20%
Recurrence: 20% - 50%
High Anal Fistulas: Treatment-Options
Dehiscence: n = 6 ( 5%)
Recurrence: n = 19 (16%)
Total: n = 120
Total Healing: n = 114 (94%)
Primary Healing: n = 95 (79%)
EDZ - Results (preliminary)
n = 148, 11/2004 – 10/2007, Follow up: 20 mo (12 - 48 mo)
Total Healing Rate with Primary Reconstruction: 84 %
Re-Rekonstruktion: n = 6 Healing (1 Stoma): n = 4 Persisting Fistula: n = 2
Re-Do: n = 19 Fistulectomy : n = 12 Persisting Fistula: n = 4 Rekonstruktion: n = 3(2)
High Anal Fistulas: Treatment-Options
Treatment Alternatives
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
Fistulectomy and
primary repair
Longterm – Seton
High Anal Fistulas: Treatment-Options
Healing Rate
Anal Fistula Plug 40% (15 – 85%)
Flap-Procedure 70% (50 – 80%)
Fistulectomy with secondary
Sphincter Reconstruction > 95%
Fistulectomy with primary
Sphincter Reconstruction 90% (80 – 95%)
Fibrine Glue 15% (10 – 70%)
Longterm – Seton 0%
Conclusion:
High Anal Fistulas: Treatment-Options
Healing RateIncontinence
(2° + 3°)
Anal Fistula Plug 40% (15 – 85%) 0%
Flap-Procedure 70% (50 – 80%) < 10%
Fistulectomy with secondary
Sphincter Reconstruction > 95% 20 – 50%
Fistulectomy with primary
Sphincter Reconstruction 90% (80 – 95%) < 20%
Fibrine Glue 15% (10 – 70%) < 10%
Longterm – Seton 0% --
Conclusion:
High Anal Fistulas: Treatment-Options
We are on the way …….
….. but we are far from perfect !
Summary
High Anal Fistulas: Treatment-Options