title: Treatment of Fistula-In-Ano with Fistula Plug - a Review Under Special Consideration of the Technique.
abstract: BACKGROUND
  In a recent Cochrane review, the authors concluded that there is an urgent need for well-powered, well-conducted randomized controlled trials comparing various modes of treatment of fistula-in-ano. Ten randomized controlled trials were available for analyses: There were no significant differences in recurrence rates or incontinence rates in any of the studied comparisons. The following article reviews the studies available for treatment of fistula-in-ano with a fistula plug with special attention paid to the technique.
  
  
  METHODS
  PubMed, Medline, Embase, and the Cochrane medical database were searched up to July 2015. Sixty-four articles were relevant for this review.
  
  
  RESULTS
  Healing rates of 50-60% can be expected for treatment of complex anal fistula with a fistula plug, with a plug-extrusion rate of 10-20%. Such results can be achieved not only with plugs made of porcine intestinal submucosa but also those made of other biological or synthetic bioabsorbable mesh materials. Important technical steps are firm suturing of the head of the plug in the primary opening and wide drainage of the secondary opening.
  
  
  CONCLUSIONS
  Treatment of a complex fistula-in-ano with a fistula plug is an option with a success rate of 50-60% with low complication rate. Further improvements in technique and better studies are needed.
authors.affiliation: Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital , Berlin , Germany.
authors.forename: Ferdinand
authors.initials: F
authors.lastname: Köckerling
authors.affiliation: Exeter Surgical Health Services Research Unit (HeSRU), Royal and Exeter Hospital , Exeter , UK.
authors.forename: Nasra N
authors.initials: NN
authors.lastname: Alam
authors.affiliation: Exeter Surgical Health Services Research Unit (HeSRU), Royal and Exeter Hospital , Exeter , UK.
authors.forename: Sunil K
authors.initials: SK
authors.lastname: Narang
authors.affiliation: Exeter Surgical Health Services Research Unit (HeSRU), Royal and Exeter Hospital , Exeter , UK.
authors.forename: Ian R
authors.initials: IR
authors.lastname: Daniels
authors.affiliation: Exeter Surgical Health Services Research Unit (HeSRU), Royal and Exeter Hospital , Exeter , UK.
authors.forename: Neil J
authors.initials: NJ
authors.lastname: Smart
keywords: biological mesh; complex anal fistula; fistula closure rate; fistula plug; incontinence