|Year : 2021 | Volume
| Issue : 1 | Page : 9-12
Autologous platelet-rich fibrin in the management of recurrent complex fistula in ano: A novel safer and cost-effective approach
Riju Ramachandran1, Anoop Vasudevan Pillai1, Vaishnavi Gunasekharan1, Suyambu Raja1, Veena Shenoy2
1 Department of General Surgery, AIMS, Kochi, Kerala, India
2 Department of Transfusion Medicine, AIMS, Kochi, Kerala, India
|Date of Submission||11-Nov-2020|
|Date of Decision||01-Dec-2020|
|Date of Acceptance||03-Dec-2020|
|Date of Web Publication||18-May-2021|
Dr. Riju Ramachandran
AG-1, Sterling Sarovar, Kosseri Lane, Edapally, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
We present the case of a 26-year-old female with Crohn's disease who had undergone multiple procedures for recurrent complex fistula-in-ano now presenting with recurrent discharge for 3 months. She underwent video-assisted anal fistula treatment (VAAFT) in our department 2 years back. The patient had financial issues and was unwilling for another sitting of VAAFT. Hence, we tried autologous platelet-rich fibrin (PRF) as a more economical alternative to fibrin sealant used in VAAFT. The patient had a very comfortable postoperative period and the fistula healed well in 3 weeks. We present this case report to highlight a new indication for autologous PRF which is already in use in healing many other types of wounds.
Keywords: Fistula, platelet-rich fibrin, video-assisted anal fistula treatment
|How to cite this article:|
Ramachandran R, Pillai AV, Gunasekharan V, Raja S, Shenoy V. Autologous platelet-rich fibrin in the management of recurrent complex fistula in ano: A novel safer and cost-effective approach. Amrita J Med 2021;17:9-12
|How to cite this URL:|
Ramachandran R, Pillai AV, Gunasekharan V, Raja S, Shenoy V. Autologous platelet-rich fibrin in the management of recurrent complex fistula in ano: A novel safer and cost-effective approach. Amrita J Med [serial online] 2021 [cited 2021 Jul 31];17:9-12. Available from: https://www.ajmonline.org.in/text.asp?2021/17/1/9/316318
| Introduction|| |
Fistula-in-ano is a very common problem prevalent in our society. Most treatment options give dismally poor cure rates. Treatment of fistula-in-ano has been revolutionized since Meinero first proposed the video-assisted anal fistula treatment (VAAFT) in 2006. This treatment has been in vogue since then and has a success rate of around 60% as per various studies., The principle of surgery is correct identification of the tract, closure of the internal opening, and allowing adequate drainage of the remaining tract after it has been fulgurated completely. Fibrin glue is sprayed or kept on the closure site of the internal opening and into the cavity of the tract. We report a case of complex recurrent fistula-in-ano after VAAFT where the treated cavity was filled with autologous platelet-rich fibrin (PRF) instead of fibrin glue and it resulted in complete healing of the tract.
| Case Report|| |
Our case is a 26-year-old doctor with Crohn's disease on immunosuppressive therapy presently in quiescent phase with a history of discharge from the perianal region and pain for the past 3 months. She initially underwent incision and drainage for a perianal abscess in 2016. Later, she developed a fistula-in-ano for which an open fistulectomy with seton placement was done. She had recurrence of symptoms in 2017 and in 2018 and underwent VAAFT treatment on both occasions. She now presented with a history of persistent perianal pus discharge since the last procedure worsened for 3 months. On examination, the patient had fistula-in-ano with an external opening at 7o'clock position around 5 cm from the anal verge and an internal opening at 6 o'clock position around 2 cm cranial to the anal verge [Figure 1]a. Active pus discharge was seen from the external opening.
|Figure 1: (a) Preoperative picture (b) Curetting the tract (c) Autologous platelet-rich fibrin (d) Instilling the platelet-rich fibrin into the tract (e) 3 months postoperative|
Click here to view
Magnetic resonance fistulogram done showed right perianal trans-sphincteric fistula with bifurcating external opening at 7 o'clock position, internal opening at 6 o'clock position, and possible early abscess formation. There was no supralevator extension [Figure 2] and [Figure 3].
Colonoscopy done was suggestive of Crohn's disease in remission and endoscopic segmental biopsy taken was reported as quiescent Crohn's disease.
As patient underwent multiple failed sittings of VAAFT with fibrin glue instillation, we wanted to try a feasible, cheaper, and better option. We had tried PRF in nonhealing ulcers with very good results. Since the patient was a doctor, we discussed and obtained consent from her for PRF being placed into the tract after VAAFT. About 120 mL of the patients' own blood was taken and was centrifuged to obtain PRF. Blood sample was collected in the blood bank in sterile conical tubes containing 10 mL in each tube as per requirement for the patient. It was then immediately centrifuged at 3000 rpm for 10 min. The separated yellow jelly-like PRF was used [Figure 1]c. Using a fistuloscope the tract was delineated, slough removed and the entire length of the wall of the fistula was fulgurated. The fulgurated treated tract was further curetted and then filled with the autologous PRF [Figure 1]b[Figure 1]d. Apart from better wound healing, an added advantage of PRF is hemostasis. The external opening sealed off in 3 weeks postprocedure. The patient was reviewed after 3 and 6 months and was found to have no recurrence of symptoms with good quality of life [Figure 1]e. The treatment was found to be cost-effective and produced better results compared to the conventional VAAFT using fibrin sealant.
| Discussion|| |
Various methods of treatment have been described for the treatment of complex fistulae with limited success, high chance of recurrence, and frequent complication. Most often patients have to undergo multiple procedures and may end up with varying degrees of anal incontinence and high recurrence. VAAFT, described by Meinero and Mori, is a recent advance in the treatment of this problem with promising results., This treatment has been in vogue since then and has a success rate of around 60% as per various studies.,
Overall healing rates for fistula-in-ano treated with fibrin glue were found to be 53% with wide variation between studies (10%–78%). Crohn's disease plagues patients with umpteen recurrences of fistula and is often very difficult to treat, having a healing rate of only 35%.
The authors have been doing VAAFT since 2012 with a success rate of around 60% in the institution. We have been using autologous PRF since 2017 to help in healing of diabetic foot ulcers and venous ulcers with very good results. Since this patient was a doctor herself and had multiple previous procedures with recurrent complex fistula, we discussed the option of filling the treated fistula tract after VAAFT with PRF costing about Rs 350 (~5$) as against Rs 8000 (100$) for fibrin. After obtaining consent we did the procedure and she was reviewed after 3 weeks at which time the fistula had completely healed.
Developed by Choukroun et al. from France, PRF is a polymerized, tetra molecular matrix of fibrin and platelets along with leukocytes, cytokines, and circulating stem cells. PRF helps to promote wound healing including difficult ones and also helps in hemostasis, bone growth, and maturation.
Many studies have shown that this biomaterial is safe without any increased inflammatory activity. Since it is a matrix of factors necessary for natural healing and hemostasis. It is useful to promote healing in difficult situations such as exposed bone. We extended this philosophy to use it in the difficult situation of a Crohn's disease with recurrent fistula and obtained excellent results.,
| Conclusion|| |
Minimally invasive procedures like VAAFT prevent the occurrence of incontinence and scarring when treating the frequent recurrences of fistula in Crohn's disease. The use of autologous PRF in such patients is safe, viable, and cost-effective and resulted in earlier complete healing.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for their images and other clinical information to be reported in the journal. The patient understand that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Staff of the hospital for help with the procedure and the patient for their trust in us.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Meinero P, Mori L. Video-assisted anal fistula treatment (VAAFT): A novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol 2011;15:417-22.
Narang SK, Keogh K, Alam NN, Pathak S, Daniels IR, Smart NJ, et al.
A systematic review of new treatments for cryptoglandular fistula in ano. Surgeon 2017;15:30-9.
Seow-En I, Seow-Choen F, Koh PK. An experience with video-assisted anal fistula treatment (VAAFT) with new insights into the treatment of anal fistulae. Tech Coloproctol 2016;20:389-93.
Jiang HH, Liu HL, Li Z, Xiao YH, Li AJ, Chang Y, et al.
Video-assisted anal fistula treatment (VAAFT) for complex anal fistula: A Preliminary evaluation in china. Med Sci Monit 2017;23:2065-71.
Garg P, Singh P. Video-assisted anal fistula treatment (VAAFT) in cryptoglandular fistula-in-ano: A systematic review and proportional meta-analysis. Int J Surg 2017;46:85-91.
Swinscoe MT, Ventakasubramaniam AK, Jayne DG. Fibrin glue for fistula-in-ano: The evidence reviewed. Tech Coloproctol 2005;9:89-94.
Cirocchi R, Farinella E, La Mura F, Cattorini L, Rossetti B, Milani D, et al.
Fibrin glue in the treatment of anal fistula: A systematic review. Ann Surg Innov Res 2009;3:12.
Choukroun J, Adda F, Schoeffler C, Vervelle A. An opportunity in perio-implantology(in French): The PRF. Implantodontie. 2001;42:55-62.
Borie E, Oliví DG, Orsi IA, Garlet K, Weber B, Beltrán V, et al
. Platelet-rich fibrin application in dentistry: A literature review. Int J Clin Exp Med 2015;8:7922-9.
Saluja H, Dehane V, Mahindra U. Platelet-rich fibrin: A second generation platelet concentrate and a new friend of oral and maxillofacial surgeons. Ann Maxillofac Surg 2011;1:53-7.
[Figure 1], [Figure 2], [Figure 3]