Regenerative medicine remove fistula and protect anus, complex anal fistula academic salon jointly wrote a new chapter in the diagnosis and treatment

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In daily life, anal fistula is a common anorectal disease, which has caused great inconvenience to people's life. At the same time, it is also a huge health hazard. In particular, the treatment of complex anal fistula has been perplexing. In order to seek a new perspective of the treatment concept of complex anal fistula, on May 21, 2021, the conference of "Complex Anal Fistula Academic Salon" sponsored by Beijing Association of Integrating of Traditional and Western Medicine was successfully held in Beijing Liaoning International Hotel.


Director Chen Chaowen from anorectal treatment center of the Peking University Third Hospital and Director Jia Shan from intestine surgery department and general surgery department of Beijing Er Long Lu Hospital,  Beijing Association of Integrating of Traditional and Western Medicine served as chairman of the "Complicated Anal Fistula Academic Salon". Directors Duan Hongyan and Zhao Guodong from Beijing Association of Integrating of Traditional and Western MedicineDirector Zheng Yi, attending physician of general surgery and anorectal surgery department of Beijing Chao-Yang Hospital, Capital Medical University(, Director Wang Xueming from anorectal treatment center of the Peking University Third Hospital  and more than 20 other anorectal field experts and scholars attended.

At the beginning of the meeting, Chairman Chen Chaowen and Director Jia Shan respectively delivered a speech of thanks to the participants and advocated everyone to communicate with each other, discuss the complex anal fistula together,  share their clinical treatment experience and the application concept of new materials, and expressed the hope that through this conference, we could enhance the understanding of complex anal fistula and achieve further improvement in the treatment of complex anal fistula. After that, Chairman Chen Chaowen and Director Jia Shan shared with participants about this conference. Everyone expresses their own ideas and discusses the methods and approaches of the treatment of complex anal fistula.

Director Zheng Yi, attending physician of general surgery and anorectal surgery department of  Beijing Chao-Yang Hospital, Capital Medical University, shared "Minimally Treatment of Anal Fistula and Application of Biological Materials --LIFT PLUG“. Director Zheng Yi said that complex anal fistula is still a difficult problem in anorectal surgery, and the traditional surgical methods have obvious disadvantages, such as large wounds, impaired anal function and low healing rate, which cannot meet the dual requirements of healing and functional protection. Protecting anal function of complex anal fistula should be at the top of all treatment goals. With the rise of minimally invasive surgery, the protection of anal function is more and more advocated in the treatment of anal fistula. Director Zheng Yi, shared a few minimally invasive treatment methods for anal fistula with everyone at the meeting, including the analysis of the characteristics of multiple surgical procedures, such as mucosal advancement flap, stapler rectal mucosal resection, thread drawing therapy (traditional Chinese medicine characteristic), video assisted anal fistula treatment (VAAFT), ligation of intersphincteric fistula tract (LIFT), and biological mesh treatment of anal fistula, etc.

 Minimally invasive treatment of anal fistula

1Mucosal advancement flap

In the treatment of high complex anal fistula, the complications are less and the curative effect is more definite. The infection is removed, the internal opening is closed, and the defect of intestinal wall is repaired by free rectal mucosal muscle flap above the incision or free anal skin flap below the incision, no external sphincter injury, small wound surface, low risk of incontinence, avoid keyhole deformity and can be repeatedly treated.

Repeated treatment increases the cure rate from 67% to 90% without exacerbating the impairment of anal function. The key to the operation is to ensure the blood supply of the mucosal flap or skin flap, and insufficient blood supply is the main reason for the failure.

2Stapler rectal mucosa resection

In 2006, Perez et al. first reported that 5 patients were followed up for 8-26 weeks without recurrence.

Injected hydrogen peroxide from outer opening of the wound to clearly find the inner opening of the wound , and the upper and lower edges of the inner opening are sutured with two half purses. The mucosa around the inner opening was removed by stapler, and the inner opening is closed at the same time to achieve the purpose of treating anal fistula.

Advantages: simple operation, minimally invasive, no damage to the sphincter, effective protection of anal function, quick postoperative recovery, less pain. Disadvantages: high cost, suitable for high sphincter with the inner opening above the tooth line or external anal sphincter anal fistula.

It embodies the essence of stapler rectal mucosa resection, and creates a precedent for the treatment of anal fistula by stapler, which is worth further discussion.

3Thread dragging therapy (traditional Chinese medicine characteristic)

Professor Lu Jingen from LongHua Hospital Shanghai University of Traditional Chinese Medicine combined traditional Chinese medicine theory  and the improved operation method of "minimally invasive" in modern surgery, by cleaning the inner and outer opening of the wound,dragging thread to achieved the purpose of safe and effective treatment of anal fistula.

216 cases of complicated anal fistula were treated with tunnel branch tube towing, and the cure rate was 96%. It protected the integrity of the shape and function of anorectum, kept the integrity of the anal sphincter reflex, reduced the scar tissue, and avoided the complications of anal incontinence, anal stenosis and anal deformity.

On this basis, it was improved by using line tube drainage method. In the early stage, silk thread was used and in the middle and late stage, single hose was used for drainage, which was convenient for washing and alleviated the pain of dressing change.

4Video assisted anal fistula treatment(VAAFT)

In 2011, Meinero et al. first proposed that 136 patients with anal fistula were treated with video assisted anal fistula treatment, with 1-year cure rate of 87%.

Features: Direct insertion into the cavity for observation, accurate identification of the inner opening and fistula, electrocautery fistula wall under direct vision. Residual fistula or chronic abscess can be identified, and although the equipment is expensive and the technique is complex, the hospital stay is short (discharge on the same day), quick recovery, more importantly, the sphincter is fully preserved and the surgical trauma is minimal.

Lack of large-scale reports, clinical effect remains to be observed.

5) Fibrin glue

An active liquid mixture, it stimulates fibroblast movement, proliferation and activity, fibronectin acts as the base of fibroblasts and pluripotent epithelial cells, and the surrounding tissue is activated by the cytoplasmic cells to become cytoplasmic. The cure rate reported abroad is 50-55%. No anal incontinence was present.

The failure is due to fibrin glue stripping and incomplete clearance of inflammatory tissue.

6Ligation of intersphincter fistula (LIFT)

Rojanasakul treated 18 cases of transsphincter anal fistula with a cure rate of 94.4% by ligating and disconnecting fistula in the sphincter space. Ligation of the intermuscular sphincter fistula - scraping off all necrotic tissue in the remaining fistula - and closure of the external sphincter defect.

Features: The internal and external sphincter are effectively preserved through the intersphincter approach. Advantages: it can cure anal fistula under the premise of not damaging the anal function. The disadvantage is that the operation is complicated and the recurrence rate is still high.

Although LIFT's success rate remains uncertain, there is no doubt that the procedure preserves anal function.

7) Biological mesh treatment of anal fistula

Biomesh treatment of anal fistula is a method developed by Cook Medical Incorporated in the United States for the treatment of anal fistula. Absorbable biomaterials obtained after the decellularization of porcine intestinal mucosa tissues are used as scaffolds and stimulate the repair and reconstruction of damaged tissues.

Acellular allogeneic dermal matrix was designed and used in our hospital for the first time in China, the cure rate of low anal fistula was 80%. However, the cure rate varies greatly among different centers, so the clinical practicality still needs to be further explored.

Through Director Zheng Yi's sharing, it can be seen that our diagnosis and treatment level and material application are making great progress and innovation in the ideal treatment plan of removing fistula and preserving anus, and the concept of minimally invasive surgery is also attracting much attention. To relieve postoperative pain, shorten the course of treatment, and solve the contradiction between the radical cure of anal fistula and the protection of anal function is bound to be the mainstream of the treatment of anal fistula in the future.


After Director Zheng Yi shared, Director Wang Xueming, deputy chief physician of the Anorectal Diagnosis and Peking University Third Hospital, brought the "Experience Sharing of Clinical Application of Anal Fistula Plug” Director Wang Xueming, aiming at the anal sphincter preservation of anal fistula surgery method, described in detail the operation of intersplice approach and the application of intraoperative biological materials. Director Wang said that the ideal goal of anal fistula treatment is to use a nearly non-invasive method to treat anal fistula, simple operation, no damage to all functions of the anus, patients without obvious pain, fast healing, no recurrence, anal and anal perianal maintain a good and beautiful shape.

At the meeting, Director Wang Xueming shared the advantages and disadvantages of anal sphincter cutting operation and anal sphincter retaining operation and matters needing attention.

1) Anal sphincter amputation surgery

Anal sphincter amputation surgery: various surgical methods based on anal fistula incision, resection, drainage treatment. It is still the main treatment.

Advantages: high cure rate >90%, low recurrence rate <10%. The operation is simple.

Disadvantages: lack of anal continence, (mainly perianal filth and incontinence) with an incidence of up to 30-40%. The wound is large and the healing time is long 4-6 weeks. Anal scar or deformity.

2) Anal fistula surgery with sphincter preservation

The anal fistula surgery with sphincter preservation has been performed for 100 years, and there have been several methods, such as thread hanging therapy, rectal mucosal flap pushing surgery, and fibrin glue sealing of the internal opening.

Advantages: No damage to anal sphincter, reduced rate of anal incontinence.

Disadvantages: different surgical treatment of the effect of the cure rate deviation is large, the cure rate is highly inconsistent.

After two major types of surgery have been popularized by science, Director Wang XueMing shared with other experts a new anal fistula treatment materials (acellular matrix biomaterial) -- anal fistula plug filling, Director Wang Xueming said that the treatment advantages of the new biomaterial are obvious, it is absorbable, non-antigenicity, good tissue compatibility, simple operation, It doesn't damage the anal sphincter, with small postoperative pain, almost no change of prognosis of the anal appearance, it is an ideal type of anal protection fistula application material. Acellular biomaterials can be added based on traditional LIFT surgery to form a kind of surgical LIFT-PLUG that combines the advantages of both. Many domestic studies have confirmed that the LIFT-PLUG surgery with acellular biomaterial fusion has a cure rate of about 94.4%. Significantly improved LIFT surgical cure rates are highly inconsistent clinical deficiencies (55%-94%).

The data show that:

From 2011 to 2012, 76 cases of operations were completed in the anorectal department of general surgery department of the Peking University Third Hospital, and the cure rate was about 94%.

Anorectal Diagnosis and Treatment Center of Peking University Third Hospital in 2016 and 2018, 95 people participated in the clinical trial of Beijing Biosis Healing, and 87 operations were completed. The statistical cure rate was 96%.

LIFT-PLUG Surgery Graphic

Probe investigation confirmed that the fistula did not need to be protruded out of the inner opening, and an intersphincter arc incision was made accurately under the guidance of the probe.

Probe guided precise dissection of the sphincter reveals a fistula of sufficient length.

The distal fistula was closed by suture of the fistula close to the internal sphincter. 

Probe was made through the incisions between the sphincters.

Scar of the external mouth was removed, and granulation tissue was drained.

Scratch and remove the contaminants and granulation tissue in the fistula, disinfect the fistula and wound surface, and flush the fistula fully with saline.

Pull out the anal fistula suppository with complete hydration to fill the fistula adequately and was suitable for tightness.

Leave an extra 0.5-1 cm in the wound between the sphincters.

Layered suture of the incisions between the sphincter muscles and the skin at the anal edge. More anal fistula plugs should be left in the wounds to be fully embedded in the tissues. The skin eversion suture was well matched.

Cut off the redundant anal fistula plug on the skin plane of the outer opening and fixed by suture.

LIFT-PLUG Surgery Summary

Advantages: Complete preservation of anal sphincter without anal incontinence. The operation makes small wound and less postoperative complications. After healing, no change in anal morphology and no obvious scar. Complications are easy to manage. Operative failure or recurrence can be repeated surgery.

Disadvantages: surgery requires relative delicacy and experience. The primary cure rate of intersphincter incisions was low. About 10% relapsed and nonunion. Treatment costs are high.



 At the end of the meeting, the participating experts discussed the future development and planning of the salon. In the future, we will continue to deepen our medical technology, give full play to our professional level, and jointly discuss the changing and diagnosis and treatment of complex anal fistula through academic exchanges, to make continuous contributions to the development of the professional field. Hereby, we would like to thank Beijing Association of the Integrating of Traditional and Western Medicine for its support to the majority of medical practitioners, which helps us improve each other's cognition and vision in the process of sharing and communicating with each other. The complex anal fistula academic salon was successfully concluded in the closing speech and warm applause of Director Chen Chaowen. Biosis Healing prompt if the perianal swelling pain, recurrent abscess, with a hand touch, perianal with a cable sclerosis, it is very likely to be anal fistula. General medical treatment cannot be eliminated, should be timely medical treatment, and should be surgery in the condition of physical conditions as soon as possible .

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