Novel applications of biomaterials in the management of parastomal hernia and anal fistula

Abstract

The aim of this thesis was to explore novel applications for both traditional and contemporary biomaterials in the management of parastomal hernia and anal fistula. Parastomal hernias can be prevented or repaired using synthetic mesh; however, reported complications include infection, fibrosis and potential bowel erosion. The prophylactic role of a cross-linked collagen implant was assessed in terms of safety, feasibility and potential efficacy. Additionally, the human host response to this implant was evaluated. There were no complications related to infection or the implant‟s proximity to the bowel. The implant had excellent biocompatibility and resistance to degradation in most patients, and although fibrovascular in-growth and ECM deposition were limited, it seems to have excellent potential for soft tissue reinforcement and, more specifically, prevention of parastomal hernias. Anal fistulas are in the main successfully treated by surgical fistulotomy, however damage to the anal sphincter complex and subsequent incontinence have led to the development of other techniques which aim to either lessen or avoid such disturbance. One strategy involves the traditional cutting seton, and a modification of this technique, the „snug‟ silastic seton was assessed. In the short-medium term, this modification was demonstrated to be an effective addition to the fistula surgeon‟s armamentarium, although minor incontinence remained a concern. Other approaches employing contemporary biomaterials, fibrin glue and porcine intestinal submucosa, are aimed at tissue repair, rather than minimizing destruction. Their success rates however are highly variable. A pilot study aiming to assess the safety and potential efficacy of an 4 alternative biomaterial, cross-linked collagen in two different physical formats, was presented. In the short-medium term, both formats were shown to be safe, and equally effective. The results justify continued research into the use of biologically derived materials to heal anal fistulas. In conclusion, although disparate pathologies were addressed, both they and the thesis are unified by demonstrating that an understanding of the specific disease pathology, wound healing, and the host response to materials (synthetic and biological) are central to their successful management.