Acellular extracellular matrix anal fistula plug: Results in high fistula-in-ano awaited

Abstract

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

To THE EDITOR

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.