title: Fibrin glue in the treatment of anal fistula: a systematic review.
abstract: BACKGROUND
  New sphincter-saving approaches have been applied in the treatment of perianal fistula in order to avoid the risk of fecal incontinence. Among them, the fibrin glue technique is popular because of its simplicity and repeatability. The aim of this review is to compare the fibrin glue application to surgery alone, considering the healing and complication rates.
  
  
  METHODS
  We performed a systematic review searching for published randomized and controlled clinical trials without any language restriction by using electronic databases. All these studies were assessed as to whether they compared conventional surgical treatment versus fibrin glue treatment in patients with anal fistulas, in order to establish both the efficacy and safety of each treatment. We used Review Manager 5 to conduct the review.
  
  
  RESULTS
  The healing rate is higher in those patients who underwent the conventional surgical treatment (P = 0,68), although the treatment with fibrin glue gives no evidence of anal incontinence (P = 0,08). Furthermore two subgroup analyses were performed: fibrin glue in combination with intra-adhesive antibiotics versus fibrin glue alone and anal fistula plug versus fibrin glue. In the first subgroup there were not differences in healing (P = 0,65). Whereas in the second subgroup analysis the healing rate is statistically significant for the patients who underwent the anal fistula plug treatment instead of the fibrin glue treatment (P = 0,02).
  
  
  CONCLUSIONS
  In literature there are only two randomized controlled trials comparing the conventional surgical management versus the fibrin glue treatment in patients with anal fistulas. Although from our statistical analysis we cannot find any statistically significant result, the healing rate remains higher in patients who underwent the conventional surgical treatment (P = 0,68), and the anal incontinence rate is very low in the fibrin glue treatment group (P = 0,08). Anyway the limited collected data do not support the use of fibrin glue. Moreover, in our subgroup analysis the use of fibrin glue in combination with intra-adhesive antibiotics does not improve the healing rate (P = 0.65), whereas the anal fistula plug treatment compared to the fibrin glue treatment shows good results (P = 0,02), although the poor number of patients treated does not lead to any statistically evident conclusion. This systematic review underlines the need of new RCTs upon this issue.
authors.affiliation: Department of General Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Cirocchi
authors.affiliation: Department of General Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy.
authors.forename: Eriberto
authors.initials: E
authors.lastname: Farinella
authors.affiliation: Department of General Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: La Mura
authors.affiliation: Department of General Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Cattorini
authors.affiliation: Department of General Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy.
authors.forename: Barbara
authors.initials: B
authors.lastname: Rossetti
authors.affiliation: Department of General Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Milani
authors.affiliation: Department of General and Emergency Surgery, St Maria Hospital, Perugia, University of Perugia, Perugia, Italy.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Ricci
authors.affiliation: Department of General and Oncology Surgery, St Maria Hospital, Perugia, University of Perugia, Perugia, Italy.
authors.forename: Piero
authors.initials: P
authors.lastname: Covarelli
authors.affiliation: Department of General Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Coccetta
authors.affiliation: Department of General and Oncology Surgery, St Maria Hospital, Perugia, University of Perugia, Perugia, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Noya
authors.affiliation: Department of General Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Sciannameo