title: Treatment of transsphincteric anal fistulas: are fistula plugs an acceptable alternative?
abstract: OBJECTIVE
  Treatments for transsphincteric, cryptoglandular anal fistulas pose risks for high recurrence rates and impaired anal continence. Anal fistula plugs have gained popularity because of reports of success without compromising the anal sphincter. To examine the benefit of the anal fistula plug, we compared its success rate with a standard treatment for transsphincteric fistulas with similar indications, the transanal mucosal advancement flap.
  
  
  METHODS
  We examined the outcomes of all patients with transsphincteric fistulas who underwent anal fistula plug repair from July 2005 to December 2006, excluding those with Crohn's disease or less than three months of follow-up. They were compared with a historical control group of patients (2001-2005) with similar transsphincteric fistulas who underwent a transanal mucosal advancement flap procedure because the anal fistula plug was not available. The same surgeons performed both procedures. Outcome was assessed from medical records or telephone follow-up.
  
  
  RESULTS
  Twenty-nine patients underwent an anal fistula plug repair, and 26 patients underwent a flap procedure. Fistula closure rates were 34 percent for plugs and 62 percent for flaps (P = 0.045). The groups were similar in all respects except that 3 percent of plug patients and 58 percent of flap patients had postoperative inpatient stays and the median follow-up was longer (279 vs. 819 days) for the flap group.
  
  
  CONCLUSIONS
  Fistula closure rates were significantly lower with anal fistula plugs than with advancement flaps. Although the low success rates for fistula plugs could be a result of patient selection, more data needs to be accrued before fistula plugs can be recommended as definitive first-line treatment for transsphincteric fistulas.
authors.affiliation: Department of Surgery, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Jennifer Y
authors.initials: JY
authors.lastname: Wang
authors.forename: Julio
authors.initials: J
authors.lastname: Garcia-Aguilar
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Sternberg
authors.forename: Michael E
authors.initials: ME
authors.lastname: Abel
authors.forename: Madhulika G
authors.initials: MG
authors.lastname: Varma
mesh_terms: D000328:Adult; D001705:Bioprosthesis; D003094:Collagen / Q000008:administration & dosage; D013505:Digestive System Surgical Procedures; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012003:Rectal Fistula / Q000601:surgery*; D012189:Retrospective Studies; D013524:Surgical Flaps; D013536:Suture Techniques; D013630:Tampons, Surgical; D016896:Treatment Outcome
chemical_list: D003094:Collagen