Ann Surg. 2020 Jun 9.doi: 10.1097/SLA.0000000000003981. Online ahead of print.

David G Jayne ¹, John Scholefield ², Damian Tolan ³, Richard Gray ⁴, Asha Senapati ⁵, Claire T Hulme ⁶, Andrew J Sutton ⁷, Kelly Handley ⁸, Catherine A Hewitt ⁸, Manjinder Kaur ⁸, Laura Magill ⁸, FIAT Trial Collaborative Group

Author information

¹University of Leeds, Leeds, UK.

²University of Nottingham, Nottingham, UK.

³Leeds Teaching Hospitals NHS Trust, Leeds, UK.

⁴Nuffield Department of Population Health Medicine Sciences Division, University of Oxford, Oxford, UK.

⁵Portsmouth Hospitals NHS Trust, Portsmouth, UK.

⁶Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.

⁷Institute of Health Economics, Edmonton, Canada.

⁸Birmingham Clinical Trials Unit (BCTU), University of Birmingham, Birmingham, UK.

Abstract

Objective: To undertake a randomized comparison of the Biodesign Surgisis anal fistula plug against surgeon's preference in treating cryptoglandular transsphincteric fistula-in-ano.

Summary background data: The efficacy of the Biodesign Surgisis anal fistula plug in healing anal fistulae is uncertain.

Methods: Participants were randomized to the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, Ligation of the Intersphincteric Fistula Tract procedure). The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and reintervention rates.

Results: Between May 2011 and March 2016, 304 participants were randomized to fistula plug or surgeon's preference. No differences were seen in FIQoL between the 2 groups at 12 months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12 months. Fecal incontinence rates improved marginally in both the groups. Complications and reinterventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs 25/137, 18%; P=0.002). The mean total costs were £2738 (s.d. £1151) for the fistula plug and £2308 (s.d. £1228) for the surgeon's preference group (mean difference +£430, P=0.0174). The average total quality adjusted life years (QALYs) gained was marginally higher in the fistula plug group. The fistula plug was 35% to 45% likely to be cost-effective across a willingness to pay threshold of £20,000 to £30,000 / QALY.

Conclusions: The Biodesign Surgisis anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12 months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS.