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►Содержание►
FIGURE8-6Theplugispulledthroughthefistulasothat
theattacheddisksitsflatonthemucosaorinamucosal “pocket.”
FIGURE8-7Thediskissecuredandtheexternalopening
leftopen.
Steps: Identifyinternalandexternalopenings Confirmtheabsenceofactiveinfection Gentlydebridethetract
Placetheplugwithinthetract Securetheplugtotheinternalopening Leaveexternalopeningwideopentoallowfordrainage
POSTOPERATIVEMANAGEMENT
Postoperativecareiscarriedoutintheoutpatientsetting.Patientsare encouragedtoavoidanystrenuousactivityfor2weeks.Manysurgeons applyadoseof10%metronidazoleointmenttwicedaily,availableasa commercialpreparationoreasilyandeconomicallycompoundedbymost hospitalpharmaciesinwhitepetrolatum.Patientsshouldbecounseled thattheymayhavepersistentdrainageforseveralmonthsafterthe procedure.Theyshouldalsobetoldtoexpectthattheremaybeplug materialextrusion.Theconsensusstatementrecommendednodietary restrictionsorbowelregimenotherthanpreventionofconstipation. Failureisdefinedastechnical,ifthereisextrusionoftheplugmaterial within1weekofthesurgery.Aminimumof3monthswaitingis suggestedpriortoconsideringthefistulaplugattempttobeafailure.

COMPLICATIONS

Complicationsofanalfistulaplugsurgeryencompassthefullrangeof complicationsforanorectalsurgery,butarethankfullyrare.Themost frequentcomplicationotherthanfailuretoclosethefistulatractis abscess,whichhasbeenhighlyvariablebutgenerallyinfrequent. Infectiouscomplicationsaremanagedwithoralantibioticsormayat timesrequiredrainageprocedureseitherintheofficeorintheoperating room.Managementoftheinfectionmayrequirereplacementoftheseton orsimpledrainageoftheexternalopeningwithpacking.Painisgenerally minimalandeasilymanagedwithoralnarcotics.Plugextrusionisa commoncomplicationandthecauseoftechnicalfailureforthese procedures.

RESULTS

Thepublishedsuccessoffistulaplugsurgeryhasbeenhighlyvariable amongdifferentgroups(Table8-1).Althoughinitialenthusiasmhas subsequentlybeentempered,andinitialsuccessrateshavenotbeen duplicated,anorectalfistulaplugsdoappeartobeeffectiveinafewselect individuals.Thegreatvariationinresultsisinpartduetovariationsin patientselection.Someauthorshaveincludedpatientswhohavehad multiplepriorattemptsatclosureandsomeonlypatientsundergoing firstattempts.Extrusionisafrequentcomplication,andismorelikelya technicalfailureorrelatedtopostoperativemanagement.Infectious complicationshavebeenreportedin25%oftheproceduresinoneseries withexpectedpooroverallresults.Fistulatractlengthisnotaccounted forinmostearlystudiesandhasbeenshownbyMcGeeetal.tobe predictiveofsuccessfulclosurebyanalfistulaplugs(seeTable8-2).
TABLE8-1 PublishedResultsfortheUseofAnalFistulaPlug
Author Totalpatients Fistulaclosure(%) Follow-up(mo)
COOKSURGISIS/BIODESIGNFISTULAPLUG
Champagneetal. 46 83 12
O’Connoretal. 20 80 10
vanKoperenetal. 17 41 7
Lawesetal. 17 24 7
Kyetal. 37 55 12
Christoforidisetal. 47 43 5
Safaretal. 35 14 4
Wangetal. 29 34 9
Schwanderetal. 60 62 12
Ellisetal. 63 81 >12
vanKoperenetal. 31 29 11
GOREBIO-AFISTULAPLUG
Stamosetal. 74 49 12
TABLE8-2 LongerFistulaTractLengthPredictsClosurewithAnal
FistulaPlug
Author
Total
patients
Tractlength
(cm)
Fistulaclosure
(%)
Follow-up
(mo)
McGeeet al.
23 >4 61 24
19 <4 21 24
MostdatahavecomefromstudiesofSurgisis(R)CookMedicalAnal FistulaPlugs.Theonlystudytocomparethetwocommerciallyavailable plugs,byBuchbergetal.,showedanimprovedproceduralsuccessratefor theGoreBio-A(R)FistulaPlug(54.5%)comparedwiththatforthe Surgisis(R)AnalFistulaPlug(12.5%).Longer-termstudiesoftheGore Bio-AFistulaPlugsshoweda49%fistulaclosurerateat1yearinamulti­institutionalprospectivetrial.
Theanalfistulaplughasbeenshowntobecost-effectivewhen comparedwithendorectaladvancementflap,evenwhenconservative estimatesofanalfistulaplugeffectivenessiscomparedwithagenerous estimateofadvancementflapofefficacy.Thisfeaturecoupledwithitslow morbidityinalmostallinvestigators’usewilllikelyensurethecontinued limiteduseofanalfistulaplugsforthetreatmentofcomplexanalfistula.

CONCLUSIONS

Treatmentofcomplexfistulascanbeextremelyfrustratingforboththe patientsandthesurgeons.Analfistulaplugshavebeenanextremely popularoptioninthepastbecauseoftheireaseofuseandgoodsafety profiles.Althoughthereisagreatvariabilityamongdifferentgroupsin thepublishedefficacyforthetreatmentoffistulas,theirsafetyis generallynotquestioned.Analfistulaplugsprovideonemoreoptionto surgeonsforthetreatmentofcomplexanalfistulas.
RECOMMENDEDREFERENCESAND READINGS
AdaminaM,HochJS,BurnsteinMJ.Toplugornottoplug:acost-effectivenessanalysisfor
complexanalfistula.Surgery2010;147:72–8. BuchbergB,MasoomiH,ChoiJ,BergmanH,MillsS,StamosMJ.Ataleoftwo(Analfistula)
plugs:isthereadifferenceinshort-termoutcomes?AmSurg2010;76:1150–3. ChampagneBJ,O’ConnorLM,FergusonM,OrangioGR,SchertzerME,ArmstrongDN.Efficacy
ofanalfistulapluginclosureofcryptoglandularfistulas:long-termfollow-up.DisColon
Rectum2006;49:1817–21. ChristoforidisD,EtzioniDA,GoldbergSM,MadoffRD,MellgrenA.Treatmentofcomplexanal
fistulaswiththecollagenfistulaplug.DisColonRectum2008;51:1482–7. CormanM,AbcarianH,BaileyHR,etal.ThesurgisisAFPanalfistulaplug:reportofaconsensus
conference.ColorectalDis2008;10:17–22. EllisCN,RostasJW,GreinerFG.Long-termoutcomeswiththeuseofbioprostheticplugsforthe
managementofcomplexanalfistulas.DisColonRectum2010;53:798–802. KyAJ,SyllaP,SteinhagenR,SteinhagenE,KhaitovS,LyEK.Collagenfistulaplugforthe
treatmentofanalfistulas.DisColonRectum2008;51:838–43. LawesDA,EfronJE,AbbasM,HeppellJ,Young-FadokTM.Earlyexperiencewiththe
bioabsorbableanalfistulaplug.WorldJSurg2008;32:1157–9. McGeeMF,ChampagneBJ,StulbergJJ,ReynoldsH,MardersteinE,DelaneyCP.Tractlength
predictssuccessfulclosurewithanalfistulaincryptoglandularfistulas.DisColonRectum
2010;53:1116–20. O’ConnorLM,ChampagneBJ,FergusonM,OrangioGR,SchertzerME,ArmstrongDN.Efficacy
ofanalfistulapluginclosureofCrohn’sanorectalfistulas.DisColonRectum2006;49:1569–
73.
RobbBW,VoglerSA,NussbaumMN,SklowB.Earlyexperienceusingporcinesmallintestinal
submucosatorepairfistula-in-ano.DisColonRectum2004;47:609. SafarB,JobanputraS,SandsD,WeissEG,NoguerasJJ,WexnerSD.Analfistulaplug:initial
experienceandoutcomes.DisColonRectum2009;52:248–52. SchultzDJ,BraselKJ,SpinelliKS,RasmussenJ,WeigeltJA.Porcinesmallintestinesubmucosa
asatreatmentforenterocutaneousfistulas.JAmCollSurg2002;194(4):541–3. SchwandnerT,RoblickMH,KiererW,BromA,PadbergW,HirschburgerM.Surgicaltreatment
ofcomplexanalfistulaswiththeanalfistulaplug:aprospective,multicenterstudy.DisColon
Rectum2009;52:1578–83. StamosMJ,SnyderM,RobbBW,etal.Prospectivemulticenterstudyofasyntheticbioabsorbable
analfistulaplugtotreatcryptoglandulartranssphinctericanalfistulas.DisColonRectum
2015;58:344–51. vanKoperenPJ,BemelmanWA,GerhardsMF,etal.Theanalfistulaplugtreatmentcompared
withthemucosaladvancementflapforcryptoglandularhightranssphinctericperianalfistula:a
double-blindedmulticenterrandomizedtrial.DisColonRectum2011;54:387–93.
vanKoperenPJ,D’HooreA,WolthuisAM,BemelmanWA,SlorsJF.Analfistulaplugforclosure
ofdifficultanorectalfistula:aprospectivestudy.DisColonRectum2007;50:2168–72. WangJY,Garcia-AguilarJ,SternbergJA,AbelME,VarmaMG.Treatmentoftranssphincteric
analfistulas:arefistulaplugsanacceptablealternative?DisColonRectum2009;52:692–97.
Chapter9
LigationoftheIntersphincteric FistulaTract(LIFT):Update withMesh
MarcC.Osborne

INDICATIONS/CONTRAINDICATIONS

FirstdescribedbyRojanasakuletal.in2007,theligationofthe intersphinctericfistulatract(LIFT)isanelegantlyconceivedsphincter­sparingprocedureforthetreatmentoffistula-in-ano.Themainconcept intheLIFTprocedureisidentificationofthefistulatractwithinthe intersphinctericgrooveanditssubsequentligationwithoutanydivision ofthesphinctermuscle.Thetechniquehasbeenusedinavarietyof circumstancesincludinglow-andhigh-transsphinctericfistulasaswellas suprasphinctericandextrasphinctericfistulas.
Incurrentpractice,LIFTismostcommonlyperformedfor transsphinctericfistulaswhenthereisadesiretoavoidthemorbidityofa fistulotomy.Otherindicationsforthesurgeryare
low-transsphinctericfistulas high-transsphinctericfistulas potentiallysuprasphincteric/extrasphinctericfistulaswherethetract
traversestheintersphinctericspace recurrentfistulas
preexistingcontinenceissues multipletracts
Contraindicationstothisapproacharefew,butmayinclude activeperinealsepsis
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