Efficacy of Plug Treatment for Complex Anorectal Fistulae: Long-term Danish Results

Abstract

Purpose Bioprosthetic plugs are appealing, allow simple, repeatable applications, preserve sphincter integrity, minimize patient discomfort, and allow subsequent surgical options when needed. However, success rates vary widely. This study assessed the healing rate in our department when both the Cook-Surgisis and the Gore fistula plugs were used and the long-term effectiveness of using anal plugs for managing anal fistulae. Methods A chart review was performed for patients who had undergone plug insertion between January 2008 and December 2015 at Copenhagen University Hospital, Hvidovre. Data were collected through a prospectively collected database. Plugs were inserted according to guidance provided by 2 experienced surgeons. Long-term results were determined by clinical visits 3, 6, and 12 months after surgery and once yearly thereafter. Results From 2008 to 2015, 36 fistula plugs were inserted. During the follow-up period with a median duration of 18 months (range, 7–60 months), the fistulae of 52.8% of the patients healed. The plug failure rate was 44.4%, and the fistula recurrence rate was 26.3%. The median time to recurrence was 12 months. The overall success rate for plug treatment in our department was 39% when adjusted for recurrence. Conclusion The use of bioprosthetic plugs to treat patients with complex anal fistulae seems to be a safe, viable option for complex fistula repair when other surgical attempts have failed. However, it should not be the treatment of choice. Further prospective randomized studies with a sufficient sample-size and standardized measurements are necessary to evaluate the efficacy of fistula plugs fully.

Improved fistula plug outcome depends on the type of plug: a single‐centre retrospective study

“…The use of plugs for patients with fistula-in-ano is popular due to ease of use and the initially reported low rates of complications including incontinence and discomfort [1,2,5,17,20,26]. The technique is appealing due to the minimal impact it has on future surgical interventions that may be required [1].…”

“…The use of plugs for patients with fistula-in-ano is popular due to ease of use and the initially reported low rates of complications including incontinence and discomfort [1,2,5,17,20,26]. The technique is appealing due to the minimal impact it has on future surgical interventions that may be required [1]. There has, however, been a huge variance in reported success rates across several systematic reviews, with healing rates ranging from 16% to 94% depending on the fistula type and type of plug used [7,14,16,17].…”

“…Multiple systematic reviews have demonstrated that initially impressive outcomes following fistula plug insertion have not been replicated in more recent studies, with healing rates similar to other techniques used in fistula management [3, 7, 14, 16, 17]. There are currently several fistula plugs available, all of which claim to improve healing for fistula‐in‐ano [1, 5, 15, 18–23]. Whilst the use of fistula plugs has not been shown to be superior to other techniques, given the variation in design it is possible that outcomes could be linked to the type of plug used [8, 16, 17].…”

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Fistula-in-ano is a common condition that is potentially difficult to treat; it can carry significant morbidity and have a substantial impact on quality of life (QoL) [1][2][3][4][5][6][7]. Transsphincteric fistulas are the second most common type of fistula-in-ano, with a treatment success rate in the region of 50%-60% irrespective of the surgical technique used [8].

…”

“…techniques used in fistula management [3,7,14,16,17]. There are currently several fistula plugs available, all of which claim to improve healing for fistula-in-ano [1,5,15,[18][19][20][21][22][23]. Whilst the use of fistula plugs has not been shown to be superior to other techniques, given the variation in design it is possible that outcomes could be linked to the type of plug used [8,16,17].…”