Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence

Abstract

Background Treating complex perianal fistulas in Crohn’s disease patients remains a challenge. Classical surgical treatments for Crohn’s disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn’s or Cryptoglandular fistula. Methods PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network. Results Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn’s disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50–60%, while in cryptoglandular fistula were around, 70–80% for setons or flaps. In Crohn’s disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips. Conclusion New surgical techniques showed better healing rates in Crohn’s disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn’s disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.

Preoperative Assessment of Perianal Fistulas With Combined Magnetic Resonance and Tridimensional Endoanal Ultrasound: A Prospective Study

“…The categories of supralevator, extrasphincteric, rectovaginal, perineal fistulas and no finding included a small number of patients. The incidence of these types of perianal fistulas was also low in recently published studies (supralevator 9.5%, extrasphincteric 0%, rectovaginal 5%) [5,49]. Nevertheless, values of diagnostic accuracy for the above fistulas in our study should be interpreted with great caution.…”

A Prospective, Single-Arm Study to Evaluate the Safety and Efficacy of an Autologous Blood Clot Product in the Treatment of Anal Fistula

“…The result is that these biologic interventions are often restricted to very specific patient populations. 11 RD2 ver.02 (RedDress Ltd, Pardes Hannah-Karkur, Israel) is an autologous whole-blood-clot treatment created from the patient's peripheral blood at the time of the procedure . 12 The treatment was found to be safe and effective in acute and chronic soft tissue wounds.…”

“…10 Recently, efforts have shifted to various biologic products, including fibrin glue and mesenchymal and adipose-derived stem cells with the hope of avoiding anal sphincter injury while permanently occluding the fistula tract. 11 However, robust clinical trials have produced only moderate success rates despite significant treatment costs. The result is that these biologic interventions are often restricted to very specific patient populations.…”

“…The result is that these biologic interventions are often restricted to very specific patient populations. 11 …”