Sierra Fernández Isabel, Balciscueta Coltell Zutoia, Uribe Quintana Natalia
Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, Valencia, Spain.
Updates Surg. 2025 May 29. doi: 10.1007/s13304-025-02270-6.
Several surgical approaches are available for managing complex cryptoglandular perianal fistulas. However, a gold standard surgical technique has not yet been established. This network meta-analysis aims to assess and compare postoperative failure and anal incontinence pooled rates for different available surgical techniques for complex cryptoglandular anal fistulas.
Systematic searches were carried out on Pubmed, Ovid, the Cochrane Library database and ClinicalTrials.gov up to June 2023. All randomized comparative trials of nine surgical techniques for cryptoglandular complex perianal fistulas in adult patients were included. A systematic review and network meta-analysis was conducted using the PRISMA-NMA methodology. The endorectal advancement flap was used as the control technique, and the odds ratios (ORs) were calculated through pairwise and network meta-analysis with random effects.
16 randomized trials were included in this study. Network meta-analysis was conducted for each outcome. Techniques, such as cutting seton, fistulotomy with sphincter reconstruction, LIFT, and VAAFT, obtained similar results in terms of technique failure to the transanal advancement flap with no statistically significant differences. PLUG (OR = 3.6 [95%CI 1.1-11.5]), fibrin glue (OR = 7.5 [95%CI 2.2-25], and platelet-rich plasma (PRP) (OR = 11.5[95%CI 1.3-99]) demonstrated a statistically significant increase in the pooled failure rate. For anal incontinence, only the cutting seton technique exhibited a higher risk of postoperative incontinence (OR = 8.6 [95%CI 1-72.5]).
Our research highlights effective therapeutic approaches for complex anal fistulas, stressing the need to customize treatment based on location, anatomy, patient characteristics, and preferences. However, it advises against using plugs, fibrin glue, PRP therapy due to lower healing rates, and the seton technique because of its potential impact on anal continence. PROSPERO number CRD42022304345.
有几种手术方法可用于治疗复杂的隐窝腺性肛瘘。然而，尚未建立金标准手术技术。这项网络荟萃分析旨在评估和比较不同可用手术技术治疗复杂隐窝腺性肛瘘的术后失败率和肛门失禁合并率。
截至2023年6月，在PubMed、Ovid、Cochrane图书馆数据库和ClinicalTrials.gov上进行了系统检索。纳入了所有关于成年患者隐窝腺性复杂性肛瘘的九种手术技术的随机对照试验。使用PRISMA-NMA方法进行系统评价和网络荟萃分析。以直肠内推进皮瓣作为对照技术，通过随机效应的成对和网络荟萃分析计算比值比（OR）。
本研究纳入了16项随机试验。对每个结局进行了网络荟萃分析。诸如切开挂线、括约肌重建的瘘管切开术、LIFT和VAAFT等技术在技术失败方面与经肛门推进皮瓣获得了相似的结果，无统计学显著差异。PLUG（OR = 3.6 [95%CI 1.1 - 11.5]）、纤维蛋白胶（OR = 7.5 [95%CI 2.2 - 25]）和富血小板血浆（PRP）（OR = 11.5[95%CI 1.3 - 99]）显示合并失败率有统计学显著增加。对于肛门失禁，只有切开挂线技术术后失禁风险较高（OR = 8.6 [95%CI 1 - 72.5]）。
我们的研究突出了复杂肛瘘的有效治疗方法，强调需要根据位置、解剖结构、患者特征和偏好来定制治疗方案。然而，由于愈合率较低，建议不要使用封堵物、纤维蛋白胶、PRP疗法，由于其对肛门节制的潜在影响而不建议使用挂线技术。PROSPERO编号CRD42022304345。
