High Anal Fistulas: Treatment-Options Fistula in ano Therapeutic Options in High Anal Fistulas A. Herold End- und Dickdarmzentrum Mannheim

High Anal Fistulas: Treatment-Options

Fistula in ano

Therapeutic Options in High Anal Fistulas

A. HeroldEnd- und Dickdarmzentrum Mannheim


subanodermalsubanodermalintersphinctericintersphincteric FistulectomieFistulectomiedistal transsphinctericdistal transsphincteric

„Standard Treatment“ of high fistulas

prox. transsphinctericsuprasphincteric Flap procedureextrasphincteric


Flap procedure


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)


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 %



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 %



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)


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%)


Treatment Alternatives

Anal Fistula Plug

Fibrine Glue

Fistulectomy and

secondary repair

Fistulectomy and

primary repair

Longterm – Seton


Anal - Fistula - Plug (AFP)

Surgisis Anal Fistula Plug


AFP - Procedure


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


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


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



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)


Anal Fistula Plug: Results (Europe)


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 %


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


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.)


Anal Fistula Plug

Fibrine Glue

Fistulectomy and

secondary repair

Fistulectomy and

primary repair

Longterm – Seton


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 %



Anal Fistula Plug

Fibrine Glue

Fistulectomy and

secondary repair

Fistulectomy and

primary repair

Longterm – Seton



Fistulectomy and Secondary Repair


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



Anal Fistula Plug

Fibrine Glue

Fistulectomy and

secondary repair

Fistulectomy and

primary repair

Longterm – Seton


Fistulectomy and Primary Repair


Fistulectomy and Primary Repair (2): Episioproctectomy


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


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


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%


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)



Anal Fistula Plug

Fibrine Glue

Fistulectomy and

secondary repair

Fistulectomy and

primary repair

Longterm – Seton


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:


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:


We are on the way …….

….. but we are far from perfect !

Summary


Documents

High Anal Fistulas: Treatment-Options Fistula in ano Therapeutic Options in High Anal Fistulas A. Herold End- und Dickdarmzentrum Mannheim