We report a case of a 63-years-old woman with a ten years history of increasing abdominal girth with associated abdominal pain. Abdomino-pelvic ultrasound and computed tomography scan revealed a large left ovarian cyst. The patient underwent laparotomy, resection of ovarian cyst and hysterectomy with bilateral ovarian resection. The removed huge mucinous cystadenoma, weighed 27 kg. Her post-operative course was unremarkable.
Chronic cutaneous non-healing fistulas very often are dehiscences of surgical or traumatic wounds that do not repair properly and progressively undergo intrafistular and perifistular fibrosis. The fibrous tissue constitutes a natural barrier to the progression of the fistula repair process and represents the major cause of non-healing and chronicization even in a context of proper vascularization. The microfractured autologous adipose graft allows to provide the tissues involved in the fibrotic process with a regenerative stimulus by MSCs (mesenchymal stem cells) contained in adipose clusters of 0.3 mm. In this context, MSCs are able to secrete cytokines with antibiotic, antifibrotic, angiogenic and analgesic effects. The micro-fragmentation technique guarantees a high regenerative effect, as the MSCs are not isolated enzymatically with the simultaneous destruction of the adipose tissue. The micro-fragmentation allows the maintainance of the structure of the adipose cluster including microvessels and allows it to amplify by 6000 times the active surface that exposes the MSCs. Our experience with the mechanical microfracturing method of lipoaspirate consists of 41 treatments. In 7 cases the graft was performed due to the presence of a non-healing cutaneous fistula, which lasted from 128 to 243 days. In 6 cases we achieved immediate repair and closure of the fistula while in one case the procedure failed. The purpose of the paper is to describe in detail our experience by an accurate description of the implemented method of the used device accompanied by the document with adequate photographic documentation.
Background: Recurrent anal fistulas present a challenge to surgeons due to the high risk of post-operative incontinence caused by repeated surgery. The correct identification of the anatomy of the main and secondary fistula tracts and the individuation of abscess cavities are fundamental for correct treatment. Intraoperative endoscopic evaluation and the complete destruction of the fistula pathway can be achieved through video-assisted anal fistula treatment (VAAFT). Furthermore, the injection of human autologous Microfractured Adipose Tissue (MFAT) processed by a Lipogems® device can be used as both a bulking agent and a regenerative technique.
Methods: A combined approach of VAAFT plus Microfractured Adipose Tissue Graft (MFAT) is proposed in order to treat recurrent and complex fistula in ano.
Results: Three cases treated with a combination of VAAFT and MFAT grafts are described. All cases had undergone multiple interventions at the perianal level over a period ranging from 1 to 15 years. One case certainly failed due to poor patient compliance, but in the remaining two cases, the patients made a complete recovery with the disappearance of symptoms over a follow-up period of one to two years.
Conclusion: The combination of video-assisted anal fistula treatment and injection of human autologous microfractured adipose tissue may be a valid, safe and feasible therapeutic option. MFAT injections are more effective in promoting tissue regeneration than simply “filling” the fistula tract and are common practice also in the treatment of Crohn’s Disease due to the immunomodulatory power of mesenchymal cells.
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