Letters To The Editor Open Access
Copyright ©2008 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Dec 14, 2008; 14(46): 7143-7143
Published online Dec 14, 2008. doi: 10.3748/wjg.14.7143
Acellular extracellular matrix anal fistula plug: Results in high fistula-in-ano awaited
Pankaj Garg, MM Institute of Medical Sciences & Research, Mullana, Haryana 133203, India
Author contribution: Pankaj Garg concieved the idea and wrote the document.
Correspondence to: Dr. Pankaj Garg, Assistant Professor, MM Institute of Medical Sciences & Research, Mullana, Haryana 133203, India. drgargpankaj@yahoo.com
Telephone: +91-98152-88741 Fax: +91-172-4648741
Received: September 3, 2008
Revised: November 10, 2008
Accepted: November 17, 2008
Published online: December 14, 2008


Song et al have reported a 100% success rate of acellular extracellular matrix (AEM) anal fistula plug in low fistula-in-ano. The results with this product in high fistula-in-ano are keenly awaited.

Key Words: Acellular extracellular matrix, Anorectal fistula, Rectal fistula, Recurrence


I read with great interest the work published by Song et al[1]. First of all, I congratulate the authors on achieving a 100% success rate with acellular extracellular matrix (AEM) anal fistula plug (AFP). This is an encouraging step to treat the notorious disease. However, there are few points that remain unanswered. First, the authors did not mention the source (origin) of the product and the company manufacturing the AEM. Second, how this product is different from the AFP (Surgisis, Cook Surgical Inc., Bloomington, Indiana, USA) is a matter of great interest. This assumes importance because various studies using Surgisis AFP have reported a success rate of 24%-87%[2,3]. Our study with Surgisis AFP in 21 patients with fistula-in-ano yielded a success rate of 71.4%. However, all of our patients had high fistulae[4]. Third, why did the authors specifically choose low fistulae in the study for which there are other effective treatment modalities available. Why high fistulae were not included in the study has not been explained in the paper. Fourth, the authors have pulled the plug from the secondary opening towards the primary opening. This is in contrast to the published studies with Surgisis AFP in which most of the authors pulled the plug from the primary opening to the secondary opening. Was there any specific reason for this variation or was it a random variation? Fifth, the authors did not explain as how did they use AEM material, like they rolled it and made a plug or they cut it into stripes and inserted those stripes into the fistula tract. The results reported are quite encouraging. However, the follow-up period of one month is too short to conclude anything convincingly. Further prospective studies with AEM plug in high fistulae would be required to substantiate these findings.


Peer reviewer: Walter E Longo, Professor, Department of Surgery, Yale University School of Medicine, 205 Cedar Street, New Haven 06510, United States

S- Editor Cheng JX L- Editor Wang XL E- Editor Zheng XM

1.  Song WL, Wang ZJ, Zheng Y, Yang XQ, Peng YP. An anorectal fistula treatment with acellular extracellular matrix: a new technique. World J Gastroenterol. 2008;14:4791-4794.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Johnson EK, Gaw JU, Armstrong DN. Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum. 2006;49:371-376.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Lawes DA, Efron JE, Abbas M, Heppell J, Young-Fadok TM. Early experience with the bioabsorbable anal fistula plug. World J Surg. 2008;32:1157-1159.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Garg P. To determine the efficacy of anal fistula plug in the treatment of high fistula-in-ano- an initial experience. Colorectal Dis. 2009;11:588-591.  [PubMed]  [DOI]  [Cited in This Article: ]