Fibrin glue and bioplastic implants in treatment of rectal fistulas (review)

INTRODUCTION: various surgical techniques are used in rectal fistula treatment however all of them can negatively effect on anal sphincter. One of the most serious complications is the development of postoperative insufficiency of the anal sphincter. The introduction of various bioplastic materials significantly influences on the development of low-traumatic operations.

AIM: to evaluate the effectiveness of fibrin glue and bioplastic implants usage in treatment of rectal fistulas.

PATIENTS AND METHODS: literature background was searched in several databases: PubMed, eLibrary and Kohrane. 842 articles on bioplastic implants and fibrin glue were found. The articles were selected according to the following criteria: the structure, consistency, relevance and evidence (the presence of supporting links to original research) of the text, information about the author’s publications’ subjects, the number of citations of the articles. The exclusion criteria were fistulas associated with inflammatory bowel diseases, post-traumatic and post-radiation ones. After analyzing the text 20 articles were selected: 19 of them in English and 1 article in Russian in the period from 2009 to 2023.

CONCLUSION: the methods presented in this review do not aggravate the muscle functional indicators of the anal sphincter; however they show high percentage of disease recurrence. Considering the safety of the techniques, they can be used as the first line of treatment for rectal fistulas. However, it is necessary to study the risk factors of fistula recurrence and to modify the methods according to them.

1. Gordon PH, Nivatvongs S. Principles and Practice of Surgery for the Colon, Rectum, and Anus. Second Edition. Quality Medical Publishing, Inc. St. Louis, Missouri. 1999; 10:242-286.

2. Shelygin Y.A., Blagodarny L.A. Handbook of coloproctology. Geotar-Media, 2014. (in Russ.).

3. Cosman BC. All's Well That Ends Well: Shakespeare's treatment of anal fistula. Dis Colon Rectum. 1998 Jul; 41(7):914-24.

4. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976; 63(1):1-12.

5. Hammond TM, Grahn MF, Lunniss PJ. Fibrin glue in the management of anal fistulae. Colorectal Dis. 2004 Sep;6(5):308-19. doi: 10.1111/j.1463-1318.2004.00676. x. PMID: 15335361.

6. Hjortrup A, Moesgaard F, Kjaergård J. Fibrin adhesive in the treatment of perineal fistulas. Dis Colon Rectum. 1991 Sep;34(9):752-4. doi: 10.1007/BF02051064. PMID: 1914738.

7. Jacob TJ, Perakath B, Keighley MR. Surgical intervention for anorectal fistula. Cochrane Database Syst Rev. 2010 May 12;(5):CD006319. doi: 10.1002/14651858.CD006319.pub2. PMID: 20464741.

8. Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects. Ann Chir Gynaecol. 1984;73(4):219-24. PMID: 6508203.

9. Herold A, et al. Coloproctology, European Manual of Medicine. Springer, 2017: 59-74.

10. Bleier JI, Moloo H, Goldberg SM. Ligation of the intersphincteric fistula tract: an effective new technique for complex fistulas. Dis Colon Rectum. 2010; 53(1): 43-46.

11. Lo O, Wei R, Foo D, et al. Ligation of intersphincteric fistula tract procedure for the management of cryptoglandular anal fistulas. Surg Pract. 2012; 16: 120–121.

12. Siripong S. The risk factors for failure and recurrence of LIFT procedure for fistula in ano. Turk J Surg. 2023 Mar 3;39(1):27-33. doi: 10.47717/turkjsurg.2023.5807

13. Wilhelm A. A new technique for sphincter-preserving anal fistula repair using a novel radial emitting laser probe. Techniques in coloproctology. 2011; 15(4): 445-449.

14. Giamundo P, Geraci M, Tibaldi L, et al. Closure of fistula-in-ano with laser - FiLaC: an effective novel sphincter-saving procedure for complex disease. Colorectal disease. 2014; 16(2): 110-115.

15. Giamundo P, Angelis M. Treatment of anal fistula with FiLaC®: results of a 10-year experience with 175 patients. Tech Coloproctol. 2021 Aug;25(8):941-948. doi: 10.1007/s10151-021-02461-4.

16. Matras H, Braun F, Lassman H, et al. Plasma clot welding of nerves. J Maxillofac Surg. 1973; 1: 236–247

17. Cronkite EP, Lozner EL, Deaver JM. Use of thrombin and fibrinogen in skin grafting. JAMA. 1944;124: 976–978.

18. Wiley C, Kazemi P, Ko D, et al. Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas, M.Sc. The American Journal of Surgery. (2009); 197: 604–608.

19. Johnson EK, Gaw JU, Armstrong DN. Efficacy of Anal Fistula Plug vs. Fibrin Glue in Closure of Anorectal Fistulas. F.R.C.S. Dis Colon Rectum. 2006 ; 49: 371–376.

20. Gubitosi A, Moccia G, Malinconico FA. Conservative anal fistula treatment with collagenic plug and human fibrin sealant. Preliminary results. Journal of Surgery. 30(1-2):46-50.

21. Armstrong DN, Johnson EK, Gaw JU. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum. 2006; 49(3):371-6.

22. Kontovounisios C, Tekkis P, Tan E, et al. Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review. Colorectal Dis. 2016 May;18(5):441-58. doi: 10.1111/codi.13330. PMID: 26990602.

23. Ratto C, Litta F, Parello A, et al. Gore Bio-A® Fistula Plug: a new sphincter-sparing procedure for complex anal fistula. Colorectal Dis. 2012 May;14(5): e264-9. doi: 10.1111/j.1463-1318.2012.02964.x.

24. Ommer A, Herold A, Joos A, et al. Gore BioA Fistula Plug in the treatment of high anal fistulas--initial results from a German multicenter-study. Ger Med Sci. 2012;10: Doc13.

25. Cintron JR, Abcarian H, Chaudhry V, et al. Treatment of fistula-in-ano using a porcine small intestinal submucosa anal fistula plug. Tech Coloproctol. 2013; 17:187–191.

26. Cestaro G, De Rosa M., Gentile M. Treatment of fistula in ano with fibrin glue: preliminary results from a prospective study. Minerva Chir. 2014 Aug;69(4):225-8.

27. Jayne D, Damian MB, Richard G, et al. A Multicenter Randomized Controlled Trial Comparing Safety, Efficacy, and Cost-effectiveness of the Surgisis Anal Fistula Plug Versus Surgeon's Preference for Transsphincteric Fistula-in-Ano. Annals of Surgery. March 2021; 273(3): p 433-441.

28. Han JG, Yi BQ, Wang ZJ, et al Ligation of the intersphincteric fistula tract plus a bioprosthetic anal fistula plug (LIFT-Plug): a new technique for fistula-in-ano. Colorectal Dis. 2013 May;15(5):582-6. doi: 10.1111/codi.12062.

29. Stamos MJ, 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 Mar;58(3):344-51.

30. Köckerling F, Alam NN, Narang SK, et al. Treatment of Fistula-In-Ano with Fistula Plug - a Review Under Special Consideration of the Technique. Smart Front Surg. 2015 Oct 16:2:55. doi: 10.3389/fsurg.2015.00055. eCollection 2015.

31. Xu Y, Tang W. Comparison of an anal fistula plug and mucosa advancement flap for complex anal fistulas: a meta-analysis. ANZ J Surg. 2016 Dec ;86(12) :978-982. Doi:10.1111/ans.13751. Epub 2016 Sep 29.

32. Lin H, Jin Z, Zhu Y, et al. Anal fistulae plug vs rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis of studies with long-term follow-up. Colorectal Dis. 2019 May;21(5):502-515. doi: 10.1111/codi.14504.

33. Pommaret E, Benfredj P, Soudan D, et al. Sphincter-sparing techniques for fistulas-in-ano. J Visc Surg. 2015 Apr;152(2 Suppl): S31-6. doi: 10.1016/j.jviscsurg.2014.08.002. Epub 2014 Oct 3. PMID: 25280598.

34. Cirocchi R, Santoro A, Trastulli S, et al. Meta-analysis of fibrin glue versus surgery for treatment of fistula-in-ano. Ann Ital Chir. 2010;81: 349-356.

35. Altomare DF, Greco VJ, Tricomi NN, et al. Seton or glue for trans-sphincteric anal fistulae: a prospective randomized crossover clinical trial. Colorectal Dis. 2011 Jan;13(1):82-6.

36. Mishra A, Shah S, Nar AS, et al. The role of fibrin glue in the treatment of high and low fistulas in ano. J Clin Diagn Res. 2013 May;7(5):876-9. doi: 10.7860/JCDR/2013/5387.2964. PMID: 23814732; PMCID: PMC3681059.

37. Portilla F, Muñoz-Cruzado M, Maestre M, et al. Platelet-rich plasma (PRP) versus fibrin glue in cryptogenic fistula-in-ano: a phase III single-center, randomized, double-blind trial. Int J Colorectal Dis. 2019 Jun;34(6):1113-1119.

38. Haim N, Neufeld D, Ziv Y, et al. Long-term results of fibrin glue treatment for cryptogenic perianal fistulas: a multicenter study. Dis Colon Rectum. 2011 Oct;54(10):1279-83.

39. Frolov S.A., Kuzminov A.M., Vyshegorodtsev D.V., and others. The experience of two-stage treatment of rectal fistulas using low-thrombin fibrin glue "Cryophyte". Russian Journal of Gastroenterology, Hepatology, and Coloproctology. 2023;33(6):44-52. (in Russ.).

40. An Y, Chen X, Tian M, et al. Comparison of clinical outcomes of anal fistula plug and endoanal advancement flap repair treating the complex anal fistula: a systematic review and meta-analysis. Updates Surg. 2023 Dec;75(8):2103-2115.

41. Chung W, Kazemi P, Ko D, et al. Anal fistulae plug and fibrin glue versus conventional treatment in repair of complex anal fistulas. Am J Surg. 2009 May;197(5):604-8. doi: 10.1016/j.amjsurg.2008.12.013.

42. Bergel S. Uber Wirkungen des Fibrins. Deutsch Wochenschr. 1909; 35:633–665.

43. Tidrick RT, Warner ED. Fibrin fixation of skin transplants. Surgery. 1944; 15:90.

44. Harvey SC. Fibrin paper as a hemostatic agent. Ann Surg. 1918; 68:66–70.

45. Frolov S.A., Titov A.Yu., Poletov N.N., et al. Historical aspects and modern surgical treatment of patients with anal sphincter insufficiency. Russian Journal of Gastroenterology, Hepatology, and Coloproctology. 2015;25(3):78–84. (in Russ.).

46. Kostarev I.V., Shelygin Yu.A., Korolik V.Yu., et al. Clinical results of a single-center prospective study evaluating the effectiveness of surgical treatment of trans and extrasphincter fistulas of the rectum using bioplastic collagen material. Annals of surgery. 2018;23(2):99–107. (in Russ.).

47. Khryukin R.Yu., Bragina A.S., Anosov I.S., et al. Stem cells derived from autologous adipose tissue as a treatment for complex anal fistulas (systematic literature review and meta-analysis). Plastic surgery and aesthetic medicine. 2025;(2):117–127. (in Russ.).