Q. What is Anal Fistula Plug & how is
this procedure done ?
Anal Fistula Plug is made up of sub
mucosa of small intestine and is a highly sophisticated absorbable material which
is absorbed/dissolved by the body in 6-8 weeks. This plug is placed and
anchored in the fistula tract by a special technique and the internal opening is
closed over it. It provides the scaffold over which body’s collagen gets
deposited and closes the fistula. The Anal Fistula Plug(AFP) has been approved
for clinical use by US FDA [United States Food & Drug Administration]
Q What are the advantages & disadvantages of Anal Fistula Plug
Non-invasive- The procedure involves no cutting,
scarring or distortion of anatomy at all.
Little pain- The procedure is associated with
comparatively little pain as
there in no cutting involved.
Early recovery- Recovery is very fast and the patient
can be back to work with in a short span.
Less morbidity- There is no new wound formation and no
extensive post operative dressings are required.
Short Hospitalization- The patient can usually be discharged in 12-24
hours after the procedure.
Can be used again after a failure- In case of a failure, the procedure
can be repeated without any risk or drawback.
NO RISK of Incontinence- There is absolutely no risk of
incontinence even in high fistulas and complex fistulas. Somebody has remarked ”For high Fistula, AFP method is a
boon sent directly from heaven”.
‘Biological’ closure- This procedure is a biological closure
of the fistula tract rather than a ‘Mechanical’ closure’ as in advancement
Minimal foreign body reaction- Studies have shown that there is
minimal foreign body reaction to the
Resistant to infection- The plug is made up of special
material which is resistant to infection. This factor helps as the plug has to
be placed in an infected environment.
High Success rate - Studies have shown the success rate of
Anal Fistula Plug treatment to be in the range of 70-87%.
PROCEDURE OF CHOICE- The Anal Fistula Plug is the
preferred treatment in
2.Long, complex fistulas
3. Recurrent fistulas
4. Horse-shoe fistulas,
5. Anterior radial fistulas
6. Crohn’s disease
7. Rectovaginal fistulas( Long term
8. Low fistula when patient doesn’t
want pain, long hospitalization, delayed recovery and scarring.
The cost of the plug is on slightly higher side which becomes a deterrent for a few.
Failure - Though Anal Fistula Plug
has high success rate, still it is not
successful in some patients. But even in these patient (with recurrence) ,
this procedure can be repeated without any harm/risk.
Extrusion- The plug can be extruded in 10-20% of cases.
formation- There can be abscess formation in 4-8%.
A Anal Fistula Plug in the fistula
tract before anchoring
LIFT (Ligation of Inter-sphicteric Fistula Tract)
In LIFT procedure, the sphincter
is not divided. A cut is given and a plane is developed between the two anal
sphincters and the fistula tract passing between the two sphincter muscles is
isolated. This portion of fistula tract between the sphincters is ligated (tied)
and excised (cut out). The internal opening of the tract is cauterized and the
portion of the fistula tract outside the sphincters is curretted, cleaned and
left open so that it can drain freely and get healed.
VAAFT ( Video- Assisted Anal Fistula Treatment)
In VAAFT, a fistulascope is
inserted through the external opening and the whole tract is visualized on
camera. The internal opening is localized through the endoscope while
visualizing the ano-rectum from outside. After this, two stitches are taken
through the internal opening so as to isolate the internal opening. After this,
the fistula tract is cauterized with a monopolar cautery electrode so as to
coagulate (burn) the fistula mucosa (lining) from internal opening to the
external opening. The necrotic burnt tissue is taken out with the help of a
brush and forceps. After this, the internal opening is lifted with the
help of two stitches taken earlier and closed with a linear cutting Stapler
which closes the tract at the level of the internal opening.