Minimal invasive approach in the management of perianal suppuration disease

Background

About one-fifth of the anal fistula are of the complex type, involving a substantial part of the sphincter
or associated with inflammation as in Crohn’s disease. The treatment of this type is often associated
with relative high recurrence and protracted course with potential risk of serious complication.
This Ph. D project was conducted to evaluate three minimal invasive treatment approaches.

• Needle aspiration of an acute simple perianal abscess may be an alternative to conventional
incision drainage with potential advantages in wound healing, functional outcome, and quality
of life.

• Video-Assisted Anal Fistula Treatment VAAFT may have a recurrence rate comparable to
fistulectomy and sphincter repair FSR in the treatment of high anal fistula and with potential
advantages in wound healing, functional outcome, and quality of life.

• Stem-cell enriched fat grafting is thought to be more efficient than standard surgical therapy
in the treatment of Crohn's anal fistula.

Aim and Objectives

The aim and objectives of the first study are to compare the outcome of needle aspiration and
postoperative antibiotics with conventional surgical incision drainage of acute perianal abscess.
Primary outcome was abscess recurrence. Secondary outcomes were fistula formation, wound
healing, quality of life and fecal continence.

The aim and objectives of the second study are to compare the outcome of VAAFT with FSR of high
cryptoglandular anal fistula. Primary outcome was fistula recurrence. Secondary outcomes were anal
manometry, quality of life and fecal continence.

The aim and objectives of the third study are to evaluate short-term efficacy and safety of using fat
graft enriched with Adipose-Derived Regenerative Cells (ADRC) as a treatment of Crohn's high anal
fistula, in terms of healing rate and adverse events.

Methods and Results

First study
A three-center randomized controlled trial, including adults with acute perianal abscess. The needle
aspiration group received Clindamycin for one week postoperatively. All included patients were
scheduled for follow-up at 2, 12 and 52 weeks postoperatively including physical examination, quality
of life assessment (SF 36 questionnaire) and fecal continence (Wexner score).
A total of 98 were included. Recurrence rate was 41% in needle aspiration and 15% in incision
drainage, with HR of 3.033 (p=0.014). Fistula formation was 15% without significant difference
between the groups. There was no significant difference in wound healing, quality of life or fecal
incontinence scores.

Second study
A single center randomized controlled trial, including adults with high anal fistula. The surgical procedures wereperformed as one-day surgery and with standard postoperative regimen. All included patients were scheduledfor follow-up at six months postoperatively including physical examination, MR scanning, anal manometry,quality of life assessment (RAND SF 36 questionnaire) and fecal continence (Wexner score).A total of 45 patients were included. Recurrence rate was 65% in VAAFT and 27% in FSR, with HR 4.18 (p=0.016), and the length of the fistula as a risk factor had a significant association with recurrence with HR 1.8(p=0.02). There was a significant difference in quality of life in favor of FSR and in anal manometry in favor ofVAAFT and a significant improvement in Wexner score in both groups. 

Third study
Adult patients with transsphincteric anal fistula and Crohn's disease in remission were included. Twosimultaneous procedures were performed as a same-day surgery, starting with liposuction from theabdominal wall followed by debridement of the fistula tract and closure of the internal fistula opening.About 30-50 ml lipoaspirate was then re-injected around the fistula tract. Using an automatedprocessing Celution® 800/IV system, ADRC were prepared and injected around the fistula tract(average of 30 million stem cells). Postoperative clinical and MRI follow-up were performed at sixmonths.
12 adult patients were included and nine (75%) had complete clinical healing and eight (67%)radiological healing of the fistula by a single treatment. Complete wound healing was achieved at 12-weeks follow-up in 67% of the patients treated. There was clear and significant improvement in thefecal incontinence score and no major adverse events were observed.

Conclusions

Needle aspiration with postoperative antibiotics cannot be recommended as alternative for surgicalincision in the treatment of acute perianal abscess. Fistula formation following acute anal abscess isnot affected by the treatment type.Fistulectomy and sphincter repair is more effective than VAAFT in the treatment of high anal fistulas.ADRC-enriched autologous lipoaspirate can be safely used in the treatment of high anal fistula in patients withCrohn's disease with high rate of success.