Fistula Healing Rate Research Articles

Implementation of laser ablation of fistula tract (LAFT) for perianal fistulas: do the results warrant continued application of this technique?

Laser Ablation of Fistula Tract (LAFT) is a novel technique for the treatment of perianal fistulas. Initial reports have shown moderate-to-good results. The aim of this study was to evaluate this implementation and the effectiveness of this technique. Patients were offered LAFT as a treatment option for their perianal fistulas at the outpatient clinic between November 2016 and April 2018. Inclusion criteria were intersphincteric and transsphincteric fistula of cryptoglandular origin [10]. Exclusion criteria were supra- or extrasphincteric fistula, Crohn's disease, presence of undrained collections or side tracts and malignancy-related fistula. The primary outcome was fistula healing rate, the main secondary outcome incidence of postoperative fecal incontinence. Healing and postoperative FISI were evaluated at our outpatient clinic during follow-up at 6 and 12weeks. A questionnaire was sent to all patients to evaluate the long-term postoperative FISI and patient satisfaction after 3months. Between November 2016 and April 2018, 20 patients [m:f = 4:16, median age 45 (27-78) years] underwent LAFT. Median follow-up was 10months (IQR 7.3months). A draining seton was placed in 15 (75%) of all patients with a median time of 12weeks (IQR 14weeks) prior to LAFT. Five intersphincteric and 13 transsphincteric fistulas were treated. Overall healing rate was 20% (4/20). The median postoperative fecal incontinence severity index (FISI) score was 0 (range 0-38); however, we found a change in continence in 39% of the patients. LAFT has now been discontinued as a treatment of cryptoglandular perianal fistulas in our centre, because of its disappointing results. Further detailed research seems to be warranted to investigate its exact indication and limitations.

Mesenchymal Stem Cells for Perianal Crohn's Disease.

Perianal fistulizing Crohn’s disease (PFCD) is associated with significant morbidity and might negatively impact the quality of life of CD patients. In the last two decades, the management of PFCD has evolved in terms of the multidisciplinary approach involving gastroenterologists and colorectal surgeons. However, the highest fistula healing rates, even combining surgical and anti-TNF agents, reaches 50% of treated patients. More recently, the administration of mesenchymal stem cells (MSCs) have shown notable promising results in the treatment of PFCD. The aim of this review is to describe the rationale and the possible mechanism of action of MSC application for PFCD and the most recent results of randomized clinical trials. Furthermore, the unmet needs of the current administration process and the expected next steps to improve the outcomes will be addressed.

Primary endotherapy for Strasberg type C bile leaks

BackgroundEndotherapy is considered by some as the treatment of choice for most external biliary fistulas after laparoscopic cholecystectomy except for those originating from isolated/disconnected ducts, as in Strasberg type C lesions. Endoscopic intervention is not generally considered among treatment options because the isolated duct cannot be opacified during cholangiography and is inaccessible with the usual endoscopic methods. MethodsOur interventional endotherapy for this type of complication consists of cannulating the isolated duct by passing a guidewire out of the cystic duct or the disruption of the common bile duct into the pathway of the biliary fistula. The key element of this endoscopic treatment is to restore the continuity of the biliary tree. Our case series (from March 2012 to September 2017) consists of 19 patients (9 males, 10 females) with Strasberg type C bile leaks. The access to the transected biliary duct was obtained by purposeful puncture of the cystic duct stump into the peritoneal cavity and then intubation of the biliary duct by a 0.035 hydrophilic guidewire. In 17 cases, we performed direct cannulation of the isolated transected duct. In 2 cases, we performed an endoscopic “step-up approach” (a 2-session variant of the technique). ResultsTechnical and clinical success rates were both 100%. Drainage form the abdominal drain stopped in a mean of 1.2 days. There was 1 recurrence after 4 weeks (attributable to displacement of the metal stent), but we were able to retreat the patient endoscopically. Our technique is minimally invasive but very effective in healing the fistulas. Operative repair, in contrast, is a major operation with increased morbidity, prolonged hospital stay, and is more costly. Moreover, on the basis of the available literature, endotherapy passing through the abdominal cavity became safe in expert centers. ConclusionThe described endoscopic treatment is innovative, safe, and effective and is applicable in tertiary-level centers but requires considerable interventional endoscopic expertise. This minimally invasive procedure can increase the rate of fistula healing and decreases the need for more aggressive and risky operative procedures.

Strategies to Optimize Anti-tumor Necrosis Factor Therapy for Perianal Fistulizing Crohn's Disease: A Systematic Review.

Tumor necrosis factor (TNF) antagonists are considered the cornerstone therapy for fistulizing perianal Crohn's disease (PCD), yet a substantial proportion of patients fail to achieve healing. Therefore, we reviewed the evidence for strategies to enhance the efficacy of TNF antagonists for PCD. A systematic search of electronic databases through July 2018 was performed to identify studies that assessed the effectiveness of TNF antagonists combined with another medical or surgical intervention for PCD; or assessed the association between anti-TNF serum concentrations and fistula healing. Twelve studies compared anti-TNF therapy alone versus a combined approach: four with surgery, three with antibiotics, and five with immunomodulators. Only two studies, both with antibiotics, were rated high quality. The addition of antibiotics to anti-TNF therapy resulted in significantly higher rates of fistula response and healing in one study, and a trend toward reduction in fistula drainage in the other. Three of four studies found higher rates of fistula healing when surgery was combined with TNF antagonists. In contrast, one of five studies found a trend toward higher rates of fistula healing in patients treated concomitantly with immunomodulators. Five observational studies assessed the association between anti-TNF concentration and fistula healing. Higher infliximab serum concentrations were consistently associated with fistula healing. In conclusion, few high-quality studies assessing strategies to optimize anti-TNF therapy for PCD exist. Although antibiotics, possibly surgery, and higher serum infliximab concentrations appear to improve fistula healing, future prospective studies are needed to determine the optimal treatment strategy.

Concise Review: Using Fat to Fight Disease: A Systematic Review of Nonhomologous Adipose-Derived Stromal/Stem Cell Therapies.

The objective of this Review is to describe the safety and efficacy of adipose stem/stromal cells (ASC) and stromal vascular fraction (SVF) in treating common diseases and the next steps in research that must occur prior to clinical use. Pubmed, Ovid Medline, Embase, Web of Science, and the Cochrane Library were searched for articles about use of SVF or ASC for disease therapy published between 2012 and 2017. One meta-analysis, 2 randomized controlled trials, and 16 case series were included, representing 844 human patients. Sixty-nine studies were performed in preclinical models of disease. ASCs improved symptoms, fistula healing, remission, and recurrence rates in severe cases of inflammatory bowel disease. In osteoarthritis, ASC and SVF improved symptom-related, functional, radiographic, and histological scores. ASC and SVF were also shown to improve clinical outcomes in ischemic stroke, multiple sclerosis, myocardial ischemia, chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, chronic liver failure, glioblastoma, acute kidney injury, and chronic skin wounds. These effects were primarily paracrine in nature and mediated through reduction of inflammation and promotion of tissue repair. In the majority of human studies, autologous ASC and SVF from liposuction procedures were used, minimizing the risk to recipients. Very few serious, treatment-related adverse events were reported. The main adverse event was postprocedural pain. SVF and ASC are promising therapies for a variety of human diseases, particularly for patients with severe cases refractory to current medical treatments. Further randomized controlled trials must be performed to elaborate potential safety and efficacy prior to clinical use. Stem Cells 2018;36:1311-1328.

Anal Fistulas in Severe Perineal Crohn's Disease: Mri Assessment in the Determination of Long-Term Healing Rates.

The European Crohn's and Colitis Organization recommends magnetic resonance imaging (MRI) of anal fistulas to decide on the drug/surgery strategy. No evidence is available on the long-term impact of MRI features on fistula healing. The aim of this study was to evaluate the benefit of combined drug/surgery strategies for the treatment of perianal Crohn's fistulas based on MRI factors at referral. The clinical event (anal abscess, new fistula tract, cellulitis), therapeutic intervention (introduction/optimization of immunosuppressant/biologics, anal surgery, intestinal resection, stoma), and MRI data were prospectively recorded for patients with Crohn's disease (CD) and anal fistulas. Healing was defined by fulfilment of all the following conditions: no discharge or pain, closure of the external opening of the fistula, no visible internal opening, no abscess, and no subsequent draining seton or drainage procedure performed during at least 1 year of follow-up. Seventy CD patients with anal fistulas and MRI evaluations were followed for 70 months. The cumulative rates of fistula healing were 25%, 40%, 50%, and 70% at 12, 24, 36, and 72 months, respectively. Severe, complex, branched, and high fistulas were associated with a less favorable outcome. Surgical closure of the tract improved the healing rates better than treatment with biologics or thiopurines. Male sex, A1 luminal phenotype, and anal ulceration at referral were independently associated with a higher healing rate. Therapeutic strategies for perianal fistulizing CD require robust anatomical and healing evaluations. Combined strategies using biologics to improve both drainage and secondary closure of the fistula tracts merit further study.

Systematic review of surgical interventions for Crohn's anal fistula.

BackgroundAnal fistula occurs in approximately one in three patients with Crohn's disease and is typically managed through a multimodal approach. The optimal surgical therapy is not yet clear. The aim of this systematic review was to identify and assess the literature on surgical treatments of Crohn's anal fistula.MethodsA systematic review was conducted that analysed studies relating to surgical treatment of Crohn's anal fistula published on MEDLINE, Embase and Cochrane databases between January 1995 and March 2016. Studies reporting specific outcomes of patients treated for Crohn's anal fistula were included. The primary outcome was fistula healing rate. Bias was assessed using the Cochrane ROBINS‐I and ROB tool as appropriate.ResultsA total of 1628 citations were reviewed. Sixty‐three studies comprising 1584 patients were ultimately selected in the analyses. There was extensive reporting on the use of setons, advancement flaps and fistula plugs. Randomized trials were available only for stem cells and fistula plugs. There was inconsistency in outcome measures across studies, and a high degree of bias was noted.ConclusionData describing surgical intervention for Crohn's anal fistula are heterogeneous with a high degree of bias. There is a clear need for standardization of outcomes and description of study cohorts for better understanding of treatment options.

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement. The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence. A retrospective review was performed at 3 university-affiliated teaching hospitals. All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded. The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed. Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics. This study was limited by its retrospective design. Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Treatment of Complex Fistula-in-Ano With a Nitinol Proctology Clip.

The treatment of complex anocutaneous fistulas remains a major therapeutic challenge balancing the risk of incontinence against the chance of permanent closure. The purpose of this study was to investigate the efficacy of a nitinol proctology clip for closure of complex anocutaneous fistulas. This is a single-center cohort study with retrospective analysis of all of the treated patients. Data were obtained from patient records and MRI reports, as well as follow-up telephone calls and clinical follow-up with endoanal ultrasonography. All of the patients were treated for high transsphincteric and suprasphincteric anocutaneous fistulas at the Digestive Disease Center, Bispebjerg Hospital, between May 2013 and February 2015. All of the patients were treated with the nitinol proctology clip. Primary outcome was fistula healing after proctology clip placement, as evaluated through clinical examination, endoanal ultrasonography, and MRI. The fistula healing rate 1 year after the clip procedure was 54.3% (19 of 35 included patients). At the end of follow-up, 17 (49%) of 35 patients had persistent closure of the fistula tracks. No impairment of continence function was observed. Treatment outcome was not found to be statistically associated with any clinicopathological characteristics. The study is limited by its retrospective and nonrandomized design. Selection bias may have occurred, because treatment options other than the clip were available during the study period. The small number of patients means that there is a nonnegligible risk of type II error in the conclusion, and the follow-up may be too short to have detected all of the failures. Healing rates were comparable with those of other noninvasive, sphincter-sparing techniques for high-complex anocutaneous fistulas, with no risk of incontinence. Predictive parameters for fistula healing using this technique remain uncertain. See Video Abstract at http://links.lww.com/DCR/A347.

Ligation of the intersphincteric fistula tract technique in the treatment of anal fistula

Background: Management of anal fistula is a challenging issue in surgical practice. No single technique is appropriate for treatment of all types of fistulas. The aim of this study was to evaluate the efficacy and safety of a new sphincter-sparing technique: ligation of the intersphincteric fistula tract (LIFT) for management of anal fistula.Methods: Over a period of 18 months from January 2015 to June 2016 twenty-one patients (12 males and 9 females) with transsphincteric anal fistula were treated with the LIFT procedure. Patients were followed up for at least six months postoperatively for fistula recurrence, rate of wound healing and effect on fecal continence.Results: Fistula healing rate was (90.5%); recurrence rate was 9.5% in the form of down staging to intersphincteric fistulas. Mean time of healing of intersphincteric wound was 32±7.4 days (ranged from 17 to 58 days). Mean time of healing of the external opening wound was 27±5.8 days (ranged from 19 to 56 days). No postoperative changes in fecal continence.Conclusions: LIFT operation is a safe and effective management of transsphincteric anal fistula, this technique has high healing rate with no effect on fecal continence.

Endotherapy for bile leaks from isolated ducts after hepatic resection: A long awaited challenge

BackgroundBile leakage is a common complication after hepatic resection [1–4] (Donadon et al., 2016; Dechene et al., 2014; Zimmitti et al., 2013; Yabe et al., 2016). Endotherapy is the treatment of choice for this complication except for bile leaks originating from isolated ducts; a condition resembling the post laparoscopic cholecystectomy Strasberg type C lesions [5–9] (Lillemo et al., 2000; Gupta and Chandra, 2011; Park et al., 2005; Colovic, 2009; Mutignani et al., 2002). In such cases, surgical repair is complex, often of uncertain result and with a high morbidity and mortality [1] (Donadon et al., 2016). On the other hand, percutaneous interventions (i.e. plugging the isolated duct with glue) are technically difficult and risky [7,8] (Park et al., 2005; Colovic, 2009). Endoscopy, thus far, was not considered amongst treatment options. That is because the isolated duct cannot be opacified during cholangiography and is not accessible with the usual endoscopic methods [5,6] (Lillemo et al., 2000; Gupta and Chandra, 2011). MethodsConsidering the pathophysiology of this type of bile leaks, it is possible to change the pressure gradient endoscopically in order to direct bile flow from the isolated duct towards the duodenal lumen, thus creating an internal biliary fistula to restore bile flow. In order to achieve this goal, we have to perforate the biliary tree into the abdomen. The key element of endoscopic treatment is to create a direct connection between the abdominal cavity and the duodenal lumen by-passing the residual biliary tree with a new technique fully explained in the paper. Our case series (from 2011 to 2016) consists of 13 patients (eight male, five female, mean age 58 years) with fistulas from isolated ducts after various types of hepatic resection. ResultsWe performed sphincterotomy and placed a biliary stent with the proximal edge inside the intra-abdominal bile collection in 11 patients (eight biliary fully-covered self-expandable metal stents; three plastic stents). In the remaining two patients we successfully cannulated the involved isolated biliary duct and we placed a bridging stent (one fully covered self-expandable metal stent; one plastic stent). Technical and clinical success (considered as fistula healing) was achieved in all 13 patients (mean fistula healing time was four days). Biliary stents were removed three to six months after atrophy of the involved duct in nine cases. In two patients the stent is still in situ. Two patients died with stent in situ due to advanced cancer at 8 and 42 months respectively. Mean follow up was 18 months (range: 8–42 months). ConclusionsThe described endoscopic treatment is innovative, safe and effective. It is applicable in tertiary level endoscopic centers and requires considerable expertise. This minimally invasive procedure can increase the rate of fistula healing and will eventually reduce the need for more aggressive and risky surgical procedures.

Higher infliximab trough levels are associated with perianal fistula healing in patients with Crohn's disease.

Infliximab has been found to be efficacious in the treatment of fistulas in the setting of Crohn's disease, even though some patients do not benefit from therapy. To assess the correlation between perianal fistula healing and trough levels of infliximab. In this cross-sectional study, we identified patients with Crohn's disease who had perianal fistulas and were treated with infliximab for at least 24weeks. We excluded patients who underwent a faecal diversion procedure or proctectomy. Predictive variables included demographics, disease phenotype, disease activity, infliximab levels, anti-infliximab antibodies. The primary outcome was fistula healing defined as the absence of drainage. The secondary outcome was complete fistula closure and mucosal healing. 117 patients were included. Patients with fistula healing had significantly higher median serum infliximab levels when compared to those with active fistulas [15.8 vs. 4.4μg/mL, respectively (P<0.0001)]. There was an incremental gain in fistula healing with higher infliximab levels. The AUC for the association between fistula healing and infliximab levels was 0.82 (P<0.0001), while the AUC for the association of infliximab levels and fistula closure was 0.69 (P=0.014). Patients with anti-infliximab antibodies had a lower chance of achieving fistula healing (OR: 0.04 [95%CI: 0.005-0.3], P<0.001). There is a significant association between serum infliximab levels and rates of fistula healing. Achieving infliximab levels ≥10.1mcg/mL in patients with Crohn's disease and perianal fistulas may improve outcomes as part of a treat-to-target strategy.

Treatment of fistula in ano with fistula plug: experience of a tertiary care centre in South Asia

Introduction Fistula in ano remains a surgical challenge. Most of the surgical procedures for this condition are associated with troublesome consequences. The use of biologic anal fistula plug (AFP) has demonstrated excellent fistula healing. Therefore, this study was done to evaluate the efficacy of the AFP in treating patients with anorectal fistulae. Methods A retrospective analysis was performed on data belonging to 51 patients with cryptoglandular anorectal fistulae, who underwent a surgical procedure using AFP. Patient’s demographics and characteristics of the fistulae were obtained from a database, which was maintained prospectively by the University Surgical Unit of the National Hospital of Sri Lanka from January 2007 to January 2016. Success was defined as closure of the external opening and absent drainage. Results 51 patients were treated with anal fistula plug (male: female=37:14) with a mean age of 42 years (SD±14.86, range26-70). Ten patients who defaulted follow-up were excluded from the analysis. Therefore, 47 procedures were left to be analysed. 29(70.7%) patients healed completely while 12(29.3%) patients failed during the follow-up period of 12 months. 24(72.7%) simple fistulae healed successfully. Recurrent plug placement had succeeded over single plug placement (83.33% vs. 68.6%).There was no statistical significance between patient’s age, sex, fistula type and its primary track with fistula healing rate(P>0.05). Conclusion Contrary to other published studies, placement of AFP was associated with much lower fistula healing rate. Most successes were seen in simple fistulae. Repeat plug placement is associated with increased success rate. Therefore, repeat plug placements may be considered in treating patients who present with a recurrence after AFP insertion.

Study of outcome of patient with faecal fistula

Background: Approximately 80% gastrointestinal fistulas occur following surgery. Due to the high morbidity and mortality associated with gastrointestinal fistula, effective treatment is important. Therefore, this study was conducted to study the outcome of management of patients of gastrointestinal fistula. Methods: 30 Patients developing the condition following surgery were included. All patients were treated either conservatively or operatively by various means and varying period of time. Treatment was focused on the correction of dehydration, controlling sepsis, management of electrolyte imbalance. Results: Younger patients had better fistula healing rate (85%) than older (70%). A high rate of spontaneous healing was observed (85%) in patients who were managed conservatively. Patients with low output fistula had better fistula closure rate as compared to high output fistula. Ileum was the most common site for fistula formation, account for 43.33% of all fistulas. Spontaneous healing rate was better in fistula involving large bowel and duodenal fistula. Patients having both anemia and hypoproteinemia had poor healing rate (72.73%) as compared to those having only anemia and hypoproteinemia. Conclusions: Conservative management with emphasis on improvement of nutrition, control of sepsis, management of fluid and electrolyte balance and control of fistula output supersedes than operative management. Operative intervention must be done in selected cases after improvement of nutritional status and control of infection.

Delayed absorbable synthetic plug (GORE® BIO-A®) for the treatment of fistula-in-ano: a systematic review.

Recent advances in the treatment of fistula-in-ano have focused on surgical techniques that preserve sphincter integrity. Plugs that obliterate the lumen of the fistula track have been proposed as one such method, and may be derived from biological or delayed absorbable synthetic materials. Biological plugs have highly variable results and have not been widely adopted. The aim of this systematic review was to assess the effectiveness and safety of a delayed absorbable synthetic plug (GORE® BIO-A®) for treatment of anal fistula. A systematic review of all literature in the English language relevant to the use of a plug to treat anal fistula and published between 1 January 2008 and 15 February 2015 was carried out by searching MEDLINE, EMBASE and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Relevant articles were identified, quality assessed using the methodological index for nonrandomized studies criteria and data were extracted by two independent researchers (SKN and NNA). The identified articles were assessed with regard to fistula healing rate, duration of follow-up and complication rates related to the use of delayed absorbable synthetic fistula plugs. Twenty six potential articles were identified from the literature search. Using the predefined inclusion and exclusion criteria, six were included in the final analysis, data extraction and data synthesis. Of these included in the review only three were prospective in design. Complete data were available for 187 of the 221 patients who underwent this treatment. The age of the participants ranged from 19 to 82years. The fistula healing rates were reported to be between 15.8% and 72.7% at a follow-up ranging between 2 and 19months. Early or delayed plug extrusion occurred in 16 (8.5%) of the 187 patients. Deterioration in continence was reported in 11 (5.8%) of 187 patients. There are insufficient high-quality data on the delayed absorbable synthetic (GORE® BIO-A®) fistula plug to draw meaningful conclusions regarding its effectiveness. It does, however, appear to be a simple and safe technique associated with low complication rates and a minor deterioration in continence in a few cases.

Using Thick Loose Seton Reduces the Incontinence and Enhances Healing Rate of High Type Fistula in Ano, a Retrospective Study

The recurrence of fistula in ano after operation is distressing for the patients. The aim of this study is to minimize the recurrence of fistula in ano after surgery and to protect from postoperative incontinence. 126 patients were presented to the clinic as a primary or a recurrent high fistula in ano. Only two cases of them were emergency. Fistulas due to malignancy, inflammatory bowel disease or tuberculosis were excluded. Thick loose silk suture was applied for 6 months. Healing rate was 91.26% after first operation, and 82% after second operation. No reported incontince. Application of thick seton is associated with low recurrence rate and no fecal incontinence.

Therapeutic management of complex anal fistulas by installing a nitinol closure clip: study protocol of a multicentric randomised controlled trial—FISCLOSE

IntroductionComplex anal fistulas are responsible for pain, faecal incontinence and impaired quality of life. The rectal mucosa advancement flap (RMAF) procedure to cover the internal opening of the fistula remains...

PTU-212 A systematic review of bioabsorbable synthetic anal fistula plug for treatment of cryptoglandular fistula in ano

Introduction Damage to the anal sphincter musculature during treatment of fistula in ano is a dreaded complication. Absorbable synthetic fistula plug have been used as a novel sphincter saving technique. The aim of this systematic review was to review the literature and assess the effectiveness of absorbable synthetic fistula plug for treatment of cryptoglandular fistula in ano. Method A systematic review of all English language literature relevant to fistula plug treatment of cryptoglandular fistula in ano, published between 1 January 2010 and 15 February 2015 was carried out using MEDLINE, EMBASE and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Relevant articles were identified, quality assessed using the MINORS criteria and the data were extracted by two researchers independently. The identified articles were assessed with regards to fistula healing rate, duration of follow up and complication rates related to the use of bioabsorbable fistula plugs. Results A total of 26 potential articles were identified from the literature search. Using the predefined inclusion and exclusion criteria, 6 articles were included for the final analysis, data extraction and data synthesis. Of the 6 studies included in the review only 3 studies were prospective in study design. Complete data were available for 187 of the 221 patients who underwent this treatment. The age of the participants ranged from 19–82 years. The fistula healing rates were reported to be between 15.8% >72.7% on follow up ranging from 2–19 months. Early or delayed plug extrusion occurred in 16 patients. A slight deterioration in continence was reported in 11 patients. Conclusion Synthetic bioabsorbable anal fistula plugs appears to be a simple and safe procedure associated with low complication rates and faecal incontinence. Given the significant heterogeneity in the study design, sample size and reported outcomes, further studies with longer follow up are needed. Disclosure of interest None Declared.

PTU-211 Novel techniques in the treatment of cryptoglandular fistula in ano: a systematic review

<h3>Introduction</h3> Fistula in ano represents a complex disease process that can be particularly challenging to treat. Several newer techniques have been developed with the intention of achieving high success rates and minimising damage to the anal sphincter complex. The aim of this systematic review was to review the published literature for novel treatment strategies and assess its effectiveness. <h3>Method</h3> A systematic review of all English language literature relevant to novel treatment strategies for cryptoglandular fistula in ano, published between 1 January 2007 and 31 Dec 2014 was carried out using MEDLINE, EMBASE and the Cochrane Library of Systematic Reviews/Controlled Trials for relevant literature. Relevant articles were identified, quality assessed using the MINORS criteria and the data were extracted by two researchers independently. The identified novel techniques were assessed with regards to the surgical procedure, fistula healing rate, length of follow up and complication rates. <h3>Results</h3> A total of 70 potential articles were identified from the literature search. Using the predefined inclusion and exclusion criteria, 21 articles were included for the final analysis, data extraction and data synthesis. Apart from two RCT, all were retrospective or prospective case series. The identified studies reported the use of novel biomaterials (adipose derived stem cells, platelet rich plasma, Human acellular dermal matrix (ADM), Permacol™ solid implant/suspension, Acellular Dermal Matrix (ADM), Acellular Extracellular Matrix (AEM), Energy devices (Fistula laser closure-FiLaC), new types of seton sutures (Comfort Drain and self-locking cable tie), Hybrid techniques (BioLIFT, LIFT-Plug and Permacol injection-advancement flap), OTSC^TMProctology clip system and Video assisted anal fistula treatment (VAAFT). The success rates of the various techniques ranged from 37.3% to 100% over a follow up period ranging from 4–81 months without any major disturbance to continence. <h3>Conclusion</h3> This systematic review has demonstrated that there have been some pioneering technological advances to treat complex cryptoglandular fistula in ano however most of these are in an early stage of evolution. Due to the significant variation in the methodology, study design, outcome reporting of the included studies, it is not possible to meaningfully compare and contrast the described novel techniques. As with most new procedures, the early promising and enthusiastic results are often difficult to reproduce. Longer follow up data is not currently available. <h3>Disclosure of interest</h3> None Declared.

Sa1264 A Randomised, Double-Blind, Placebo-Controlled, Parallel Group, Multi-Centred Pilot Study to Assess the Symptomatic Treatment of Ulcerative Colitis With Cannabidiol

symptoms. Overall fistula healing rates at wk 52 was 52%, and an analysis utilizing the last-observation-carried-forward showed no significant difference between the two groups at wk 52 in either complete cessation of drainage (MED 55% vs. COMBO 50% [p=0.83], Figure) or PDAI (MED 3 vs. COMBO 3.5 [p=0.86]). Time to cessation of drainage was also similar in both groups. Conclusion: There was no significant benefit to seton placement prior to starting anti-TNF therapy in terms of perianal fistula healing in CD. While setons should be used when clinically indicated, their routine use with an anti-TNF to facilitate fistula healing if large abscesses are absent was not supported by this study.