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

2. „Standard Treatment“ of high fistulas
subanodermal
intersphincteric Fistulectomie
distal transsphincteric
prox. transsphincteric
suprasphincteric Flap procedure
extrasphincteric

3. Flap procedure

4. Mucosal - flap: Results (1)
Type n Persistence Recurrence
Transsph % 17 %
Suprasph % 37 %
Rectovag % 40 %
Recurrent f % 47 %
Crohn`s f % 48 %
Athanasiadis S (1995): Int J Colorect Dis S. 153

5. Mucosal - flap: Results (1)
Type n Persistence Recurrence Healing
Transsph % 17 % 74 %
Suprasph % 37 % 43 %
Rectovag % 40 % 37 %
Recurrent f % 47 % 15 %
Crohn`s f % 48 % 24 %
Athanasiadis S (1995): Int J Colorect Dis S. 153

6. Mucosal - flap: Results (2)
Author Year n Type Rec „Incont“
Williams mixed 0 % 62 %
Garcia-Aguilar mixed 2 % 10 %
Wedell trans 3 % 0 %
Girona trans/supra 3/8 % 8/19 %
Oh mixed 13 % -
EDZ trans 10 % 0 %
Athanasiadis trans 20 % 21 %
Athanasiadis mixed 21 % -
Schouten trans 25 % -
Jones trans 31 % -
Gustafsson trans 45 % 11 %
Baeten mixed 63 % (3Ja.) 17 %

7. EDZ - Results (transsphincteric)
n = 88, 04/2001 – 04/2004, Follow up: 35 mo ( mo), 18% recurrent, 12% horse shoe, without Crohn´s,
Transsphincteric: n = 41
Total Healing: n = 35 (85 %)
Primary Healing: n = 27 (66 %)

8. EDZ - Results (transsphincteric)
n = 88, 04/2001 – 04/2004, Follow up: 35 mo ( mo), 18% recurrent, 12% horse shoe, without Crohn´s,
Transsphincteric: n = 41
Total Healing: n = 35 (85 %)
Primary Healing: n = 27 (66 %)
Persistence: n = 10 (24 %)
Recurrence: n = 4 (10 %)
Re-Flap healed: n = 2
Fistulectomy: n = 5
Excision + Reconst: n = 1
Still persisting: n = 6
Total Healing Rate with Flap: 71 % (Incontinent: 0%)

9. Treatment Alternatives
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
primary repair
Longterm – Seton

10. Anal - Fistula - Plug (AFP)
Surgisis Anal Fistula Plug

11. AFP - Procedure

12. AFP: First Prospective Trial
n = 25 Pat. (transsphincteric Fistulas), kryptoglandular, FU: 13 wks.
n Healing
Fibrine %
Plug % 9
Johnson E, Armstrong D (USA): Dis Colon Rectum 2006 S. 371

13. AFP: Prospective Trial
n = 20 Pat. (36 transsphincteric Fistulae), Crohn`s Disease, FU: 10 Mo. (3 – 24)
n Healing
Simple Fistula %
Komplex Fistula 7 45 %
Total % 9
O`Connor L, Armstrong D (USA): Dis Colon Rectum 2006 S. 1569

14. Anal Fistula Plug: Results (USA)
Author Year n FU Healing
Robb (ASCRS 2004) Mo
Champagne (Armstrong) Mo
Poirier (Abcarian) Mo
Ky (New York) Mo
Christoforidis (Mineapolis) Mo
Cintron (USA) Mo
Abbas (Efron LA) Mo
Safar (Wexner) Mo

15. Anal Fistula Plug: Results (USA)
Author Year n FU Healing
Robb (ASCRS 2004) Mo 65 %
Champagne (Armstrong) Mo 83 %
Poirier (Abcarian) Mo 54 %
Ky (New York) Mo 81 %
Christoforidis (Mineapolis) Mo 40 %
Cintron (USA) Mo 54 %
Abbas (Efron LA) Mo 24 %
Safar (Wexner) Mo 14 %

16. Anal Fistula Plug: Results (Europe)
Author Year n FU Healing
Lenisa (I) Mo 85 %
Van Koperen (NL) Mo 41 %
Garg (Ind) Mo 66 %
Bohe (Sw) Mo 66 %
Thekkinkattil (UK) Mo 39 %
AFP-Workshop < 6 Mo %

17. 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

18. Anal Fistula Plug: Results Germany (Follow up 6 Mo.)
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 %

19. Treatment Alternatives
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
primary repair
Longterm – Seton
Author Year n FU Healing
Abel (USA) Mo 75 %
Cintron (USA) Mo 72 %
Patrlj (Yug) Mo 70 %
Lindsey (GB) Mo 43 %
Chan (GB) Mo 60 %
Sentovich (USA) Mo 69 %
Zmora (USA) Mo 33 %
Buchanan (GB) Mo 16 %
Loungnarath (USA) < 26 Mo 23 %

20. Treatment Alternatives
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
primary repair
Longterm – Seton

21. Fistulectomy and Secondary Repair

22. Secondary Repair: Results
Author Year n Success
Keighley (GB) %
Browning (GB) %
Fang (USA) %
Christiansen (DK) %
Laurberg (USA) %
Ctercteko (USA) %
Yoshioka (GB) %
Jacobs (NL) %
Fleshman (USA) %
Wexner (USA) %
Arnaud (F) %
Engel (NL) %
Oliveira (USA) %
Mölle (CH) %
Halverson (USA) %
EDZ (D) %
Total: 35 Studies: Success rate 75 % (41 – 89 %)

23. Treatment Alternatives
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
primary repair
Longterm – Seton

24. Fistulectomy and Primary Repair

25. Fistulectomy and Primary Repair (2): Episioproctectomy

26. Primary Repair: Results
Author Year n Type Dehiscence Recurr. Incontinence
Parakash (Ind) distal - 2,5 % -
Lux (D) mixed 0 0% 20 % (1+2°)
Christiansen (DK) mixed - 15 % 21% (1+2°)
Gemsenjäger (CH) mixed 5 % 5 % 5 %
Lewis (GB) mixed - 9,5 %
Roig (E) mixed 4 % 10 % 24% (1+2°)
Perez (E) mixed - 6 % 12 %
Herold (D) mixed 8% (14%) 6 % -
Perez (E) mixed 0 6 % (improved)
Herold (D) mixed 5% (11%) 6 % no 3°

27. Primary Repair: Results correlated with involved Sphincter (1)2 3

28. √ √ Primary Repair: Results correlated with involved Sphincter (2)
Dehiscence: 0% - 20%
Recurrence: 20% - 50% √
2,5% √
4 %

29. EDZ - Results (preliminary)
n = 148, 11/2004 – 10/2007, Follow up: 20 mo ( mo)
Total: n = 120
Total Healing: n = 114 (94%)
Primary Healing: n = 95 (79%)
Re-Rekonstruktion: n = 6
Healing (1 Stoma): n = 4
Persisting Fistula: n = 2
Dehiscence: n = 6 ( 5%)
Recurrence: n = 19 (16%)
Re-Do: n = 19
Fistulectomy : n = 12
Persisting Fistula: n = 4
Rekonstruktion: n = 3(2)
Total Healing Rate with Primary Reconstruction: 84 %

30. Treatment Alternatives
Anal Fistula Plug
Fibrine Glue
Fistulectomy and
secondary repair
primary repair
Longterm – Seton

31. Conclusion: 40% (15 – 85%) Anal Fistula Plug Flap-Procedure
Healing Rate
Anal Fistula Plug
40% (15 – 85%)
Flap-Procedure
70% (50 – 80%)
Fistulectomy with secondary
Sphincter Reconstruction
> 95%
Fistulectomy with primary
90% (80 – 95%)
Fibrine Glue
15% (10 – 70%)
Longterm – Seton 0%

32. Conclusion: 40% (15 – 85%) Anal Fistula Plug 0% Flap-Procedure
Healing Rate
Incontinence (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
90% (80 – 95%)
< 20%
Fibrine Glue
15% (10 – 70%)
Longterm – Seton --

33. ….. but we are far from perfect !
Summary
We are on the way …….
….. but we are far from perfect !