Fibrin glue for Anal Fistulae

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Fibrin glue for Anal Fistulae
Bruce D. George, John Radcliffe Hospital, Oxford
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Traditional treatment of anal fistula
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Seton in high ano-vaginal fistula
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Prior to anal fistula surgery

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Influence of anal ultrasound on management of
anal fistula

• 38 consecutive patients undergoing EUA
• All pre-op physiology and ultrasound
• Surgeon blinded to results at time of EUA
• Surgeon shown results in theatre
• Surgical management affected in 7 (29 of
  fistulae)
• 2 occult sphincter defect
• 3 reclassification of fistula
• 2 identification of fistula
• Colorectal Disease 2002 4 118-22.

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Fibrin Glue
Simple Repeatable No wound less pain no
scarring Sphincter mechanism undisturbed Other
treatment options still available Early return to
normal activities
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1914-18 1944 Facilitate skin
grafting 1970 Commercially available fibrin in
Europe 1990 Lange et al GI fistulae 1991 Hjortr
up et al Perineal sinus 1993 Abel et al
autologous glue for anal fistulae 1998 FDA
approval
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Fibrin Glue for Anal Fistulae
Abel 1993 2/5 40 Venkatesh 1993 12/21 57 Ai
tola 1999 1/10 10 Citron 1999 50/85 59 Pat
rlj 2000 51/69 74 El-Shobaky 2000 24/30 80
Sentovich 2001 17/20 85 Total 157/240 65
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Trial of Fibrin Glue for Anal Fistulae
Pre-operative assessment clinical anorectal
physiology and ultrasound continence
score Operative assessment 2 groups happy to
lay open (Simple) not happy to lay open
(High/complex)
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Trial of Fibrin Glue for Anal Fistulae
Intra-operative randomisation to fibrin glue or
conventional treatment Follow-up (median 17
months, range 6-21) Primary end-points healing
and patient satisfaction Secondary end points
continence scores,anorectal physiology, pain
scores, return to normal activities.
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Simple Fistulae
6 fibrin glue 3 healed 7 fistulotomy 7
healed p0.06 Fistulotomy group more
satisfied No difference/change in pain scores,
continence scores, physiology or return to normal
activities
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Complex Fistulae
13 Fibrin glue 9 healed 16 conventional 2
healed p0.006 (13 loose seton, 3 advancement
flap) Satisfaction scores greater in fibrin glue
group Continence scores worse in conventional
group No difference in pain scores, physiology or
return to normal activities
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Complications of Fibrin Glue treatment

• Perianal abscess 1 patient

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Summary of Oxford results

• Trial patients 12/19 healed 63
• Post trial 9/10 healed 90
• Overall 21/29 72

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Conclusions

• Simple Fistulae
• Fistulotomy is superior to fibrin glue treatment
• High/complex Fistulae
• Fibrin glue treatment may be superior to
  conventional therapy

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Unfavourable factors for fibrin glue
Short, wide, straight fistula (eg
rectovaginal) Sepsis Poor healing (radiotherapy,
Crohns) Poor technique of glue delivery
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Other considerations
Risk of transmitting infection human (pooled)
fibrinogen viral risks bovine thrombin prion
risk allergic
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The Place of Fibrin Glue for Anal Fistula

• Multicentre trial of Fibrin glue in high/complex
  fistula versus advancement flap repair
• Probably just another club in the bag