Int J Colorectal Dis DOI 10.1007/s00384-015-2142-9
LETTER TO THE EDITOR
Novel application of anal fistula plug for the treatment of chronic anastomotic sinus Dimitrios Patsouras & Alexis Schizas & Mark L. George
Accepted: 21 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: A persistent anastomotic sinus may develop following an anastomotic leak after a low pelvic anastomosis. Defunctioning the anastomosis with a loop ileostomy does not prevent the leakage but decreases the septic complications of a leak. The reported incidence of an anastomotic leak after low anterior resection is between 2.6 and 26.2 % [1]. The presence of an anastomotic sinus is usually identified by the water-soluble enema performed prior to considering reversal of the ileostomy and restoring bowel continuity. The sinus given time may close spontaneously; however, if the sinus does not heal, surgical intervention may be required before bowel continuity can be restored. A chronic presacral sinus in an irradiated area is unlikely to heal and, if large, will delay the closure of the ileostomy and probably results in poor function of the neorectum. The management of an anastomotic sinus varies according to the surgeon’s preference; the location, size and type of anastomotic sinus; as well the performance status and the preference of the patient. Many methods have been described, including deroofing of the anastomosis, resection and re-anastomosis, resection and permanent stoma, pull-through operations, sealing of the track with tissue glue and endo-sponge treatment. We report a case of a patient with low anastomotic sinus treated and healed with an anal fistula plug. D. Patsouras (*) : A. Schizas : M. L. George Department of Colorectal Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, UK e-mail: [email protected] A. Schizas e-mail: [email protected] M. L. George e-mail: [email protected]
A 36-year-old woman with middle third rectal cancer had a low anterior resection with a defunctioning loop ileostomy following a long course of neo-adjuvant chemoradiotherapy. Histology confirmed a ypT3aN0M0 moderately differentiated adenocarcinoma of the rectum completely excised. She then had adjuvant chemotherapy. Prior to reversal of the ileostomy, a water-soluble enema was performed, identifying an anastomotic sinus extending to the presacral space which was also confirmed with flexible sigmoidoscopy. There was no history of pelvic sepsis following surgery. Following discussion regarding treatment options, the patient was keen to avoid any further major surgery. An examination under anaesthesia was performed, and an anal fistula plug was inserted into the anastomotic sinus in attempt to heal the persistent sinus. The patient was positioned in the lithotomy position. The defect in the anastomosis was identified at 5 cm from the anal verge with gentle passage of a probe to confirm the position of the sinus. The sinus opening was 5 mm in diameter and 6 cm in length. Curettage and washout of the track was performed with H2O2. An anal fistula plug (Biodesign Fistula Plug; Cook Medical) was prepared after being immersed in sterile saline and inserted in to the sinus track with the wider end of the plug at the opening of the sinus at the anastomosis. The plug was sutured in place, and the sinus opening was closed with 3-0 Vicryl. The patient’s postoperative recovery was uncomplicated, and she was discharge the same day. Six weeks later, a repeat water-soluble enema showed that the sinus had healed. The ileostomy was reversed without any complication. Three months later, the patient reported good functional results and, occasionally, she takes loperamide. Anastomotic leak following restorative rectal surgery is not an uncommon event. Failure of healing results in persistence of the dehiscence, with formation of a sinus tract. The incidence of chronic presacral sinus as a complication of
Int J Colorectal Dis
anastomotic failure and the incidence of resolution are unknown. A significant number will go clinically unnoticed and only become radiologically apparent at a later stage or on routine assessment of anastomotic integrity prior to stoma closure. A presacral sinus persisting for at least 12 months after low anterior resection is a rare complication, but it is associated with a significant risk of severe secondary complications, a high number of re-interventions and, consequently, impaired quality of life. Metachronous tumours arising within persisting anastomotic sinuses many years after initial surgery have also been described. Variables techniques have been described for the treatment of anastomotic sinuses. Most surgeons adopt the simple, watch and wait strategy in which they observe the patient and repeat imaging regularly to monitor the healing of the sinus. Most of the small leaks in asymptomatic patients will resolve with time. In asymptomatic patients with small persistent sinus, closing of the ileostomy can be considered after discussion of the pros and cons of this approach. When the watch and wait policy is insufficient to achieve complete healing, other management strategies may be applied. Swain described a method of injecting the sinus with fibrin glue after curettage with 100 % success rate at a mean follow-up of 11 months [2]. Alternatively, Whitlow described a method for treating anastomotic sinuses by deroofing of the anastomosis, by dividing the common wall between the sinus and the neorectum [3], although the long-term consequences of faecal contact with a presacral cavity are unknown. Endosponge treatment is effective with success rates from 56 to 100 % [4]. It can be used as an outpatient treatment with changing of the sponge every 3–4 days. This technique has a considerable impact on the patient and is demanding in terms of effort, time and availability; furthermore, the costs are considerable. When the above measures fail, a re-do anastomosis or a colo-anal pull-through procedure is a salvage procedure to restore intestinal continuity before considering excision of the neorectum and permanent faecal diversion. The use of a fistula plug for anastomotic sinus was a logical broadening of its application in anal fistula treatment. It consists of an acellular non-cross-linked extracellular matrix sheet, derived from porcine small intestinal submucosa. It is composed of over 90 % collagen and 10 % glycoproteins, proteoglycans, glycosaminoglycans and lipids. The matrix is
rolled into a cylindrical shape, presenting a highly efficient scaffold to allow infiltration of the patient’s connective tissue. When it is implanted, host tissue cells and blood vessels colonize the graft which becomes repopulated with patient cells and tissues. It has an inherent resistance to infection and provides no foreign body or giant cell reaction. The extracellular matrix is completely replaced by host tissues within 3 to 6 months. The anal fistula plug for the treatment of non-complex chronic anastomotic sinus is minimally invasive and has minor morbidity. It can be performed as a day case, and it may be used repeatedly as the patient will not be adversely affected by insertion of the plug. It stimulates tissue remodelling and allows ingrowth and replacement by the patient’s own tissues, leading to full closure of anal fistula tract and, consequently, anastomotic sinus healing. The early use of this technique may prevent long periods of observation and resultant delay in restoration of intestinal continuity. Failure of the fistula plug does not affect future performance of other techniques. The disadvantages of this procedure are that it can only be performed in those patients with a low anastomotic sinus. Further contraindication would be a wide sinus opening, persistent sepsis, several tracts and allergy to the product. The surgical treatment of anastomotic sinus remains to be a difficult problem. The use of fistula plug for anastomotic sinus appears to be a safe procedure associated with minor morbidity. The fistula plug can be a reasonable alternative for the treatment of non-complex chronic anastomotic sinus.
References 1. Tan WS, Tang CL, Shi L, Eu KW (2009) Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 96:462–472 2. Swain BT, Ellis CN (2004) Fibrin glue treatment of low rectal and pouch-anal anastomotic sinuses. Dis Colon Rectum 47:253–255 3. Whitlow CB, Opelka FG, Gathright JB, Beck DE (1997) Treatment of colorectal and ileoanal anastomotic sinuses. Dis Colon Rectum 40: 760–763 4. Van Koperen PJ, van der Zaag ES, Omloo JM, Slors JF, Bemelman WA (2011) The persisting presacral sinus after anastomotic leakage following anterior resection or restorative proctocolectomy. Color Dis 13(1):26–29
LETTER TO THE EDITOR
Novel application of anal fistula plug for the treatment of chronic anastomotic sinus Dimitrios Patsouras & Alexis Schizas & Mark L. George
Accepted: 21 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: A persistent anastomotic sinus may develop following an anastomotic leak after a low pelvic anastomosis. Defunctioning the anastomosis with a loop ileostomy does not prevent the leakage but decreases the septic complications of a leak. The reported incidence of an anastomotic leak after low anterior resection is between 2.6 and 26.2 % [1]. The presence of an anastomotic sinus is usually identified by the water-soluble enema performed prior to considering reversal of the ileostomy and restoring bowel continuity. The sinus given time may close spontaneously; however, if the sinus does not heal, surgical intervention may be required before bowel continuity can be restored. A chronic presacral sinus in an irradiated area is unlikely to heal and, if large, will delay the closure of the ileostomy and probably results in poor function of the neorectum. The management of an anastomotic sinus varies according to the surgeon’s preference; the location, size and type of anastomotic sinus; as well the performance status and the preference of the patient. Many methods have been described, including deroofing of the anastomosis, resection and re-anastomosis, resection and permanent stoma, pull-through operations, sealing of the track with tissue glue and endo-sponge treatment. We report a case of a patient with low anastomotic sinus treated and healed with an anal fistula plug. D. Patsouras (*) : A. Schizas : M. L. George Department of Colorectal Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, UK e-mail: [email protected] A. Schizas e-mail: [email protected] M. L. George e-mail: [email protected]
A 36-year-old woman with middle third rectal cancer had a low anterior resection with a defunctioning loop ileostomy following a long course of neo-adjuvant chemoradiotherapy. Histology confirmed a ypT3aN0M0 moderately differentiated adenocarcinoma of the rectum completely excised. She then had adjuvant chemotherapy. Prior to reversal of the ileostomy, a water-soluble enema was performed, identifying an anastomotic sinus extending to the presacral space which was also confirmed with flexible sigmoidoscopy. There was no history of pelvic sepsis following surgery. Following discussion regarding treatment options, the patient was keen to avoid any further major surgery. An examination under anaesthesia was performed, and an anal fistula plug was inserted into the anastomotic sinus in attempt to heal the persistent sinus. The patient was positioned in the lithotomy position. The defect in the anastomosis was identified at 5 cm from the anal verge with gentle passage of a probe to confirm the position of the sinus. The sinus opening was 5 mm in diameter and 6 cm in length. Curettage and washout of the track was performed with H2O2. An anal fistula plug (Biodesign Fistula Plug; Cook Medical) was prepared after being immersed in sterile saline and inserted in to the sinus track with the wider end of the plug at the opening of the sinus at the anastomosis. The plug was sutured in place, and the sinus opening was closed with 3-0 Vicryl. The patient’s postoperative recovery was uncomplicated, and she was discharge the same day. Six weeks later, a repeat water-soluble enema showed that the sinus had healed. The ileostomy was reversed without any complication. Three months later, the patient reported good functional results and, occasionally, she takes loperamide. Anastomotic leak following restorative rectal surgery is not an uncommon event. Failure of healing results in persistence of the dehiscence, with formation of a sinus tract. The incidence of chronic presacral sinus as a complication of
Int J Colorectal Dis
anastomotic failure and the incidence of resolution are unknown. A significant number will go clinically unnoticed and only become radiologically apparent at a later stage or on routine assessment of anastomotic integrity prior to stoma closure. A presacral sinus persisting for at least 12 months after low anterior resection is a rare complication, but it is associated with a significant risk of severe secondary complications, a high number of re-interventions and, consequently, impaired quality of life. Metachronous tumours arising within persisting anastomotic sinuses many years after initial surgery have also been described. Variables techniques have been described for the treatment of anastomotic sinuses. Most surgeons adopt the simple, watch and wait strategy in which they observe the patient and repeat imaging regularly to monitor the healing of the sinus. Most of the small leaks in asymptomatic patients will resolve with time. In asymptomatic patients with small persistent sinus, closing of the ileostomy can be considered after discussion of the pros and cons of this approach. When the watch and wait policy is insufficient to achieve complete healing, other management strategies may be applied. Swain described a method of injecting the sinus with fibrin glue after curettage with 100 % success rate at a mean follow-up of 11 months [2]. Alternatively, Whitlow described a method for treating anastomotic sinuses by deroofing of the anastomosis, by dividing the common wall between the sinus and the neorectum [3], although the long-term consequences of faecal contact with a presacral cavity are unknown. Endosponge treatment is effective with success rates from 56 to 100 % [4]. It can be used as an outpatient treatment with changing of the sponge every 3–4 days. This technique has a considerable impact on the patient and is demanding in terms of effort, time and availability; furthermore, the costs are considerable. When the above measures fail, a re-do anastomosis or a colo-anal pull-through procedure is a salvage procedure to restore intestinal continuity before considering excision of the neorectum and permanent faecal diversion. The use of a fistula plug for anastomotic sinus was a logical broadening of its application in anal fistula treatment. It consists of an acellular non-cross-linked extracellular matrix sheet, derived from porcine small intestinal submucosa. It is composed of over 90 % collagen and 10 % glycoproteins, proteoglycans, glycosaminoglycans and lipids. The matrix is
rolled into a cylindrical shape, presenting a highly efficient scaffold to allow infiltration of the patient’s connective tissue. When it is implanted, host tissue cells and blood vessels colonize the graft which becomes repopulated with patient cells and tissues. It has an inherent resistance to infection and provides no foreign body or giant cell reaction. The extracellular matrix is completely replaced by host tissues within 3 to 6 months. The anal fistula plug for the treatment of non-complex chronic anastomotic sinus is minimally invasive and has minor morbidity. It can be performed as a day case, and it may be used repeatedly as the patient will not be adversely affected by insertion of the plug. It stimulates tissue remodelling and allows ingrowth and replacement by the patient’s own tissues, leading to full closure of anal fistula tract and, consequently, anastomotic sinus healing. The early use of this technique may prevent long periods of observation and resultant delay in restoration of intestinal continuity. Failure of the fistula plug does not affect future performance of other techniques. The disadvantages of this procedure are that it can only be performed in those patients with a low anastomotic sinus. Further contraindication would be a wide sinus opening, persistent sepsis, several tracts and allergy to the product. The surgical treatment of anastomotic sinus remains to be a difficult problem. The use of fistula plug for anastomotic sinus appears to be a safe procedure associated with minor morbidity. The fistula plug can be a reasonable alternative for the treatment of non-complex chronic anastomotic sinus.
References 1. Tan WS, Tang CL, Shi L, Eu KW (2009) Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer. Br J Surg 96:462–472 2. Swain BT, Ellis CN (2004) Fibrin glue treatment of low rectal and pouch-anal anastomotic sinuses. Dis Colon Rectum 47:253–255 3. Whitlow CB, Opelka FG, Gathright JB, Beck DE (1997) Treatment of colorectal and ileoanal anastomotic sinuses. Dis Colon Rectum 40: 760–763 4. Van Koperen PJ, van der Zaag ES, Omloo JM, Slors JF, Bemelman WA (2011) The persisting presacral sinus after anastomotic leakage following anterior resection or restorative proctocolectomy. Color Dis 13(1):26–29
