EFFECTIVENESS OF AUTOLOGOUS PLATELET RICH PLASMA IN THE TREATMENT OF HIGHT PERIANAL FISTULA.

Yasser A. Orban and Ashraf Goda. General Surgery Department, Faculty of Medicine, Zagazig University. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 02 August 2019 Final Accepted: 04 September 2019 Published: October 2019


Patients and methods:-
A prospective study from September 2016 to February 2019, 16 patients with final diagnosis of high perianal fistula were prepared for perianal fistula management using autologous PRP at the Surgery Department in Zagazig University. All patients were appropriately discussed, and their consent was obtained.
All patients were clinically examined by taking history and digital rectal examination, and preoperatively investigated by complete blood count (CBC), PT, PTT, INR, liver and kidney functions, hepatitis B, C viral markers and MRI fistulogram.
All patients received preoperative oral metronidazole 500 mg tid for 5 days and did single enema in the morning of the day surgery.

Procedure: Preparation of platelet rich plasma:
Precautions before the procedure: the patient should stop any non-steroidal anti-inflammatory drugs, steroids, anticoagulants and antiplatelets at least 10 days preoperatively as these drugs interfere with platelet functions. 20 ml blood was sampled from the patient into two 10 ml syringes containing anticoagulant, Na citrate. The syringes were prepared to be used in the centrifuge by cutting the plunger and fingers grip ( fig. 1A). We adopted double spin technique for PRP preparation using (800D centrifuge ® ) ( fig. 1B). The first spin was at speed 1000 rotation per minute (RPM) for 10 mints, and the second one was at speed 3000 RPM for another 10 minutes. The initial centrifugation is to separate red blood cells followed by a second centrifugation to concentrate platelets in the smallest final plasma volume and we discard the superficial platelet poor plasma ( fig. 1C). Platelet count was measured in the blood sampled from the patient and in the PRP to confirm the success of the process of the separation of the PRP then activated by adding calcium gluconate 10%; every 9 ml were activated by 1ml calcium gluconate.

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The operation: The surgical procedure was performed under spinal anesthesia in lithotomy position. A complete anorectal examination was performed to identify the fistula's external opening, tract and internal opening.
Identification of the internal opining was also carried out by irrigating of the fistulous tact using methylene blue through the external opening and noticing the coming out of the dye from the internal opening while an anoscope was inserted.
Probing and curettage of the fistulous tract was done using a piece of gauze between two strings ( fig. 2A) and different sizes of curettes, then irrigation of the fistulous tract by saline and hydrogen peroxide to clear the tract from debris and insures hemostasis of the inside of the tract after curettage.
The fistulous tract was filled with activated autologous platelet rich plasma which is delivered by syringe ( fig. 2B) and left to form gel, and the tissue around the tract was infiltrated by activated PRP. Finally, the internal opening is closed by simple sutures using polyglactin 3-0. Follow up is performed at the outpatient clinic every week for 2 months then monthly for 12 months. During each visit, the patients under went clinical assessment for anal pain, incontinence, discharge and/or infection. The procedure was considered successful if the patient became asymptomatic (no pain with closed external opening). Failure of the surgical procedure was considered when pain, suppuration and/or external opening persisted after 6 months.

Results:-
from September 2016 to February 2019, we had 16 patients with a diagnosis of high perianal fistula, 9 males and 7 females ( fig. 3) with mean age 32 years (table 1) and follow-up period for 12 months. The most common presentations were pain, discharge, recurrent perianal infection. None of our patients had thrombocytopenia with average platelet count 234.38x 10 3 /mm 3 . Platelet count in the PRP was doubled at least with the mean platelet count in prepared PRP about 608.69x 10 3 /mm 3 (table 2).
We considered recurrence if the patient had persistent symptoms for 6 months postoperatively (pain, discharge, persistent external fistulous opening or abscess formation). We had 14 patients of complete healing of the external opening of them two patients (12.5%) developed abscesses, one at two months postoperatively and the other at 4 months postoperatively which necessitated surgical drainage. Another two patients (12.5%) had healing failure and persistent external opening for more than six months (table 4).
According to our study the duration of healing was 24.86± 5.39 days (table 5) in 14 patients who showed healing while the remaining two patients showed persistent external opening.

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We had a clinical success rate of 75% (12 patients out of 16 were completely healed with no recurrence throughout the follow up period). Only 4 patients (25%) had recurrence in the form of persistent external opening or develop an abscess (table 6).

Discussion:-
Fistula surgery remains a matter for colorectal surgeons and an exhausting process for patients with impaired quality of life. Simple fistula is treated usually by fistulotomy, that provides healing for about 90% of patients with low risk of incontinence. 6 The main problem lies in the treatment of complex perianal fistula, as fistulotomy represents an unacceptable risk of incontinence in these patients. 7 Platelet α-granules contain mitogenic and chemotactic growth factors (GF) and associated healing molecules in an inactive form, important in wound healing, such as platelet-derived growth factor (PDGF), transforming growth factors β1, β2, β3, platelet-derived angiogenesis factor, insulin-like growth factor 1, platelet factor 4 (PF-4), epidermal growth factor, epithelial cell grow factor, vascular endothelial cell growth factor (VEGF), basic fibroblast growth factor and others cytokines. During normal wound healing, trapped platelets become activated and degranulate, resulting in releasing of α-granule content. The secreted growth factors immediately bind to the external surface of cell membranes in the wound via transmembrane receptors in mesenchymal stem cells, osteoblasts, fibroblasts, endothelial cells, and epidermal cells. 8,9 This work aimed to evaluate the effect of the use PRP in when it is used as adjunct in the treatment of high perianal fistula In our study, we had 16 patients in the middle age group with mean age 32.94 ± 9.34. nine males and 7 females were included The gold standard technique for the treatment of complex fistula is likely the advancement flap. In most series recurrence rates range from 0% to 33%. 10 Sentovich in 2003, showed that single treatment with fibrin glue achieved 60 percent fistulas closure. Retreatment with fibrin glue brought the successful number of fistula tracts closed to 69 percent. Bowel function and fecal incontinence were not altered by the fibrin-glue treatment. Late recurrences (>6 months) occurred in 6 percent patients 11 .
In our study, we used autologous platelet rich plasma as adjunct in the treatment of high perianal fistula and obtained cure rates of 75%. As regard incontinence, our study we had no case develop fecal incomitance.

Conclusion:-
Platelet rich plasma is promising in the treatment of high perianal fistula without affection of fecal continence.