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Treatment of complex anal fistulas presents an ongoing challenge to colorectal surgeons. The anal fistula plug is an attractive definitive option due to its minimal risk of incontinence, simple design, and easy application. Our objective was to compare the Cook Surgisis® AFP(TM) plug and the newer Gore Bio-A® plug in the management of complex anal fistulas. A retrospective chart review of patients treated with Cook and Gore fistula plugs between August 2007 and December 2009 was performed. Success was defined as closure of all external openings and absence of drainage and abscess formation. Twelve Cook patients underwent 16 plug insertions and 10 Gore patients underwent 11 plug insertions. The overall procedural success rate in the Gore group was 54.5 per cent (6 of 11) versus 12.5 per cent (2 of 16) in the Cook group. The reasons for failure were unknown in the majority of patients and plug dislodgement in two patients. Our short-term results with the Gore fistula plug suggest a higher procedural success rate in comparison to the Cook plug. Patients should be cautioned regarding potentially high failure rates; however, longer follow-up and a larger patient population are needed to confirm significant differences in fistula plug efficacy.
DESPITE EFFORTS TO FIND an ideal treatment for anal fistulas, they remain an ongoing challenge to colorectal surgeons driving them to continue developing new techniques and devices. Fistulas have been classified as simple or complex. Simple fistulas are generally low fistulas with single tracts and carry a low risk of incontinence when treated.! A complex anal fistula is defined as a fistula in which treatment puts a patient at a higher risk of incontinence. An anal fistula may be termed "complex" when the tract involves greater than 30 per cent to 50 per cent of the sphincter muscle; it is anterior in a woman; or the patient has a history of preexisting incontinence, Crohn's disease, or local irradiation.2
The goals of treatment for complex fistulas are achievement of high healing rates, closure of all external openings, and eradication of perineal sepsis with minimal to no effect on continence.3 Numerous treatment options are available and include fistulotomy, cutting setons, application of fibrin glue, and use of endoanal advancement flaps, all with variable success rates. Regrettably, some...