Biologics in Colorectal Surgery

Anal Fistulas

Complex anal fistulas present significant treatment challenges. Standard-of-care procedures such as LIFT (ligation of intersphincteric fistula tract) and advancement flap surgery have limited healing rates and high recurrence risks, often compromising sphincter integrity and quality of life.

Biologic Augmentation for Colorectal Surgery

PRP and stromal vascular fraction (SVF) offer regenerative potential as adjuncts to sphincter-preserving surgery.

Healing rates of cryptoglandular fistulas improved by up to

89%

with adjunct autologous biologics.^1-10

‍

Biologics enhance healing and reduce recurrence of anal fistulas.

Biologic Augmentation for Colorectal Surgery

Scientific Insights

Twelve studies have assessed the use of adjunct autologous biologics alongside surgical treatment for anal fistulas, demonstrating significant improvements in healing rates for both cryptoglandular and Crohn’s-diseaseassociated fistulas.

Cryptoglandular Fistulas^1-10

‍

Crohn’s Disease^1-3,11-15

‍

A: Standard treatments (LIFT / advancement flap)

B: + PRP

C: +SVF and PRP

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References

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Key Takeaways

Biologics should be added to sphincter-preserving procedures to enhance healing and reduce recurrence
Combination therapy (SVF + PRP) shows promising results
Autologous biologics are safe, customizable, and amplify surgical outcomes

Study Limitations

No high-level evidence studies available
Heterogeneity in study designs and patient populations
Limited long-term data and small sample sizes in some pilot studies

_{Note: Different PRP and MSC devices from several manufacturers were used in these studies.}

Biologic Augmentation for Colorectal Surgery

References

Seifarth C, Lehmann KS, Holmer C, Pozios I. Healing of rectal advancement flaps for anal fistulas in patients with and without Crohn’s disease: a retrospective cohort analysis. BMC Surg. 2021 Jun;21(1):283. doi: 10.1186/s12893-021-01282-4. PMID: 34088303; PMCID: PMC8178918
Gaertner WB, Burgess PL, Davids JS, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2022;65(8):964-985. doi:10.1097/DCR.0000000000002473
Stellingwerf ME, van Praag EM, Tozer PJ, Bemelman WA, Buskens CJ. Systematic review and meta-analysis of endorectal advancement flap and ligation of the intersphincteric fistula tract for cryptoglandular and Crohn’s high perianal fistulas, BJS Open. 2020;4(1):166-167. doi:10.1002/bjs5.50249
Schouten WR, Arkenbosch JHC, van der Woude, .J. et al. Efficacy and safety of autologous adipose-derived stromal vascular fraction enriched with platelet-rich plasma in flap repair of transsphincteric cryptoglandular fistulas. Tech Coloproctol. 2021;25:1301-1309. doi:10.1007/s10151-021-02524-6
Bak MTJ, Witjes CDM, Dwarkasing RS, Arkenbosch JHC, Schouten WR, van Veen JC, van Dongen JA, Fuhler GM, van der Woude CJ, de Vries AC, et al. Additional intraoperative autologous-derived platelet-rich stroma to transanal flap repair for the treatment of cryptoglandular transsphincteric fistulas in a tertiary referral center: long-term outcomes of a prospective pilot study. Bioengineering. 2025;12:105. doi:10.3390/bioengineering12020105
Tutino R, Di Franco S, Massani M, et al. Autologous adipose-derived stromal vascular fraction and platelet concentrates for the treatment of complex perianal fistulas. Tech Coloproctol. 2023;27:135-143. doi:10.1007/s10151-022-02675-0
Rajasekaran C, Subha Avinash Y, Abineshwar NJ, R A, Sridhar J, Kanth J R A. Efficacy of platelet-rich plasma in the treatment of anal fistula – a prospective study. J Neonatal Surg. 2025;14(8S):478-485. Available from: https://jneonatalsurg.com/index.php/jns/article/view/2561
Ramachandran R, Gunasekharan V, Pillai AV, Raja S, Nair AS. Fibrin glue versus autologous platelet-rich fibrin - comparison of effectiveness on the cohort of patients with fistula-in-ano undergoing video-assisted anal fistula treatment. J Minim Access Surg. 2022;18(3):443-449. doi:10.4103/jmas.jmas_297_21
Cwaliński J, Hermann J, Paszkowski J, Banasiewicz T. Assessment of recurrent anal fistulas treatment with platelet-rich plasma. Arq Gastroenterol. 2021;58(2):185-189. doi:10.1590/S0004-2803.202100000-32
Abdollahi A, Emadi E, Hamidi Alamdari D. Autologous platelet-rich-plasma injection and platelet-rich fibrin glue interposition for treatment of anal fistula resistant to surgery. Gastroenterol Hepatol Bed Bench. 2023;16(3):292-296. doi:10.22037/ghfbb.v16i2.2719
Potenza AE, Nachira D, Sacchetti F, et al. Effectiveness of autologous emulsified stromal vascular fraction tissue injection for the treatment of complex perianal fistulas in inflammatory bowel diseases patients: a pilot study. Therap Adv Gastroenterol. 2024;17:17562848241263014. doi:10.1177/17562848241263014
Arkenbosch JHC, van Ruler O, Dwarkasing RS, Fuhler GM, Schouten WR, van Oud-Alblas MB, et al. Stromal vascular fraction with platelet-rich plasma injection during surgery is feasible and safe in treatment-refractory perianal fistulising Crohn’s disease: A pilot study. Aliment Pharmacol Ther. 2023;57:783-791. doi:10.1111/apt.17347
Goulas P, Karakwta M, Menni AE, et al. Management of complex perianal fistulas using platelet-rich plasma and adipose-derived mesenchymal stem cells: a case series. Cureus. 2025;17(1):e77495. doi:10.7759/cureus.77495
Dawoud C, Girgis K, Stift A, et al. Treatment of anal fistulas with Obsidian RFT®: just another autologous compound platelet-rich fibrin foam?. Tech Coloproctol. 2024;28:93. doi:10.1007/s10151-024-02968-6
Bak M, Witjes C, Arkenbosch J, Dwarkasing R, van Dongen J, Fuhler G, Schouten R, van der Woude J, de Vries A, van Ruler O. Platelet-rich stroma during surgery for treatment-refractory perianal fistulizing Crohn’s disease: long-term outcomes of a pilot study. J Crohns Colitis. 2024;18(Suppl 1):i1050-i1051. doi:10.1093/ecco-jcc/jjad212.0668