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P412 Efficacy and safety of additional autologous platelet-rich stroma in transanal mucosal advancement flap repair of complex cryptoglandular anal fistulas

J. Arkenbosch*1, O. van Ruler2, W. Deijl2, J. Stevens3, A. de Vries4, J. van der Woude4, E. de Graaf2, R. Schouten1,2

1Erasmus Medical Center, Department Colorectal surgery, Rotterdam, The Netherlands, 2Ijsselland Hospital, Department Colorectal surgery, Capelle a/d Ijssel, The Netherlands, 3Bergman Clinics, Department Reconstructive surgery, Bilthoven, The Netherlands, 4Erasmus Medical Center, Department Gastroenterology, Rotterdam, The Netherlands

Background

Treatment of complex cryptoglandular fistulas is challenging and associated with high recurrence rates. Flap repair fails in almost one of every three patients, probably due to chronic inflammation in the remnants of the fistulous tract. Mucosal advancement flap and platelet rich plasma (PRP) combined with progenitor cells from autologous Stromal Vascular Fraction (SVF), obtained from liposuction, could suppress chronic inflammation and therefore improve success rates. We aimed to assess the feasibility, safety and efficacy of additional injection of autologous SVF combined with PRP (Platelet Rich Stroma; PRS) in flap repair of complex cryptoglandular fistulas.

Methods

All patients with complex cryptoglandular fistulas who underwent transanal advancement flap repair between December 2017 and October 2018 were included after informed consent. Inclusion criteria included complex fistulas with only one internal opening (or a second one very close by) and absence of pelvic sepsis. All patients underwent standardised transanal mucosal repair and standardised preparation of autologous PRS. A preoperative MRI and postoperative MRI following the diagnosis of ‘clinical healing’ (closure of the internal and external openings at physical examination) were performed.

Results

This pilot study includes 22 consecutive patients (12:10 male:female; median age 44.0 (IQR 33.6–55.0). Follow-up data of at least 4 months are available for 18 of these patients to date. All patients had one or more previous operations ranging from curating the fistula tract and leaving a seton in place to previous mucosal advancement (3/18) or ligation of the intersphincteric fistula tract (LIFT; 2/18). Clinical healing was reached in 16 out of 18 (89%) patients after a median postoperative follow-up of 6 months (IQR 5–7). Two of the 18 patients did not show clinical healing at their last consultation at 4 months follow-up. Of the available 14 MRIs to date (4 are pending), 13 showed complete closure of the fistula tract. Some patients experienced transient severe postoperative pain. One patient developed a haematoma due to liposuction. One patient experienced postoperative haemorrhage underneath the mucosal flap.

Conclusion

In 18 patients with cryptoglandular fistula treated with the addition of autologous SVF and PRP during transanal advancement flap repair, 93% (13/14) indeed showed a complete fibrosed fistula tract at MRI. The addition of autologous PRS appears to be feasible, safe, cheap and highly promising. Further research could focus on the effects of PRS on Crohn’s fistula.