To plug or not to plug: A cost-effectiveness analysis for complex anal fistula

BACKGROUND: Complex anal fistulas are unsuitable for fistulotomy because of the risk of fecal incontinence. The anal fistula plug (AFP) has demonstrated fistula healing without sphincter division. This study aims to evaluate the cost-effectiveness of the AFP compared to the endoanal advancement flap (EAAF) as an alternative sphincter-preserving option for complex anal fistulas. METHODS: The study included 24 patients who underwent treatment for complex anal fistulas. Healing and complication rates of a prospective cohort of AFP patients (n=12) were compared to a retrospective cohort of patients who underwent EAAF (n=12). Cost data were collected after validated healthcare reporting standards. A cost-effectiveness analysis was performed, including extensive modeling of fistula healing rates. RESULTS: Both cohorts (12 AFP patients and 12 EAAF patients) had similar patient demographics and fistula characteristics. Fistula healing was achieved in 50% (5/12) of AFP patients and 33% (4/12) of EAAF patients (P=.680). Median clinical follow-up was 28 weeks for the AFP patients and 14 weeks for the EAAF patients, whereas median recurrence time was 17.6 weeks (range, 0.4-43.9) and 12.6 weeks (range, 2-34.3), respectively. Use of the AFP instead of the EAAF saved $1,588 (95% confidence interval [CI], $1,211-$1,965; P>.0001), and 1.5 hospital days per healed fistula (P=.0002). This cost-saving effect persisted and amounted to $825 (95% CI, $133-$1,517; P=.022) when the cost estimates were adjusted for the reduction in the hospital length of stay. Extensive modeling over a large range of fistula healing rates confirmed the cost-effectiveness of the AFP. CONCLUSION: The AFP is a cost-saving procedure for complex anal fistulas compared to the EAAF.