Regenerative and Endoscopic Treatment of Complex Recurrent Fistula in Ano: When Technology Supports Clinical Treatment

Abstract

Background: Recurrent anal fistulas present a challenge to surgeons due to the high risk of post-operative incontinence caused by repeated surgery. The correct identification of the anatomy of the main and secondary fistula tracts and the individuation of abscess cavities are fundamental for correct treatment. Intraoperative endoscopic evaluation and the complete destruction of the fistula pathway can be achieved through video-assisted anal fistula treatment (VAAFT). Furthermore, the injection of human autologous Microfractured Adipose Tissue (MFAT) processed by a Lipogems® device can be used as both a bulking agent and a regenerative technique. Methods: A combined approach of VAAFT plus Microfractured Adipose Tissue Graft (MFAT) is proposed in order to treat recurrent and complex fistula in ano. Results: Three cases treated with a combination of VAAFT and MFAT grafts are described. All cases had undergone multiple interventions at the perianal level over a period ranging from 1 to 15 years. One case certainly failed due to poor patient compliance, but in the remaining two cases, the patients made a complete recovery with the disappearance of symptoms over a follow-up period of one to two years. Conclusion: The combination of video-assisted anal fistula treatment and injection of human autologous microfractured adipose tissue may be a valid, safe and feasible therapeutic option. MFAT injections are more effective in promoting tissue regeneration than simply “filling” the fistula tract and are common practice also in the treatment of Crohn’s Disease due to the immunomodulatory power of mesenchymal cells.