Endorectal advancement flap: are there predictors of failure?

Identification of epithelialization in high transsphincteric fistulas

Background

At present, transanal advancement flap repair (TAFR) is the treatment of choice for transsphincteric fistulas passing through the upper and middle third of the external anal sphincter. It has been suggested that epithelialization of the fistula tract contributes to the failure of the treatment. The aim of this study was to assess the prevalence of epithelialization of the fistula tract and to study its effect on the outcome of TAFR and TAFR combined with ligation of the intersphincteric fistula tract (LIFT).

Methods

Forty-four patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Nine of these patients underwent a combined procedure of TAFR with LIFT. In all patients the fistula tract was excised from the external opening up to the outer border of the external anal sphincter. In patients undergoing TAFR combined with LIFT an additional central part of the intersphincteric fistula tract was excised. A total of 53 specimens were submitted. Histopathological examination of the specimens was carried out by a pathologist, blinded for clinical data.

Results

Epithelialization of the distal and intersphincteric fistula tract was observed in only 25 and 22% of fistulas, respectively. There was no difference in outcome between fistulas with or without epithelialization.

Conclusions

Epithelialization of high transsphincteric fistulas is rare and does not affect the outcome of TAFR and TAFR combined with LIFT.

Advancement flap repair: a good option for complex anorectal fistulas

BACKGROUND

Rectal advancement flap is a popular option for treatment of complex anal fistula. Although early outcomes vary, concerns remain about postoperative continence, long-term healing, and its role in patients with Crohn's disease and anovaginal fistulas.

PURPOSE

This study aimed to report long-term outcomes in patients with complex fistula disease.

PATIENTS

Patients who were undergoing rectal advancement flap for anal fistula were included in the study.

DESIGN

Patients were contacted to determine the status of their fistula disease, their bowel function, and their degree of fecal incontinence.

MAIN OUTCOME MEASURES

The main outcomes measured were healing rate and continence.

RESULTS

There were 98 patients, 43 men and 55 women, mean age 53 ± 14 years. Fifty-eight had cryptoglandular fistulas, and 40 (41%) had IBD (33 had Crohn's disease). Seventy-seven of 98 patients had perianal fistulas, and all 77 underwent seton drainage before advancement flap. Twenty-one women had anovaginal fistulas. Average postoperative length of stay was 3 ± 1 days. There were no mortalities. Follow-up was possible in 75 patients, a mean of 7 ± 3 years after surgery. Primary healing occurred in 54 (72%) patients. Twenty-one patients (28%) underwent further treatment, and 12 (57%) healed after a second advancement flap. Four more patients healed after more than 2 flaps or fistulotomy leading to an overall healing rate of 70 of 75 (93%). Patients with Crohn's disease had lower healing rates than those with cryptoglandular fistulas (87% vs 98%). Thirty-two patients (43%) had normal fecal continence before flap, and 43 (57%) had normal fecal continence after flap.

CONCLUSION

Advancement flap is a good option for patients with complex anal fistulas.

Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas

Background

Video-assisted anal fistula treatment (VAAFT) is a novel minimally invasive and sphincter-saving technique for treating complex fistulas. The aim of this report is to describe the procedural steps and preliminary results of VAAFT.

Methods

Karl Storz Video Equipment is used. Key steps are visualization of the fistula tract using the fistuloscope, correct localization of the internal fistula opening under direct vision, endoscopic treatment of the fistula and closure of the internal opening using a stapler or cutaneous-mucosal flap. Diagnostic fistuloscopy under irrigation is followed by an operative phase of fulguration of the fistula tract, closure of the internal opening and suture reinforcement with cyanoacrylate.

Results

From May 2006 to May 2011, we operated on 136 patients using VAAFT. Ninety-eight patients were followed up for a minimum of 6 months. No major complications occurred. In most cases, both short-term and long-term postoperative pain was acceptable. Primary healing was achieved in 72 patients (73.5%) within 2–3 months of the operation. Sixty-two patients were followed up for more than 1 year. The percentage of the patients healed after 1 year was 87.1%.

Conclusions

The main feature of the VAAFT technique is that the procedure is performed entirely under direct endoluminal vision. With this approach, the internal opening can be found in 82.6% of cases. Moreover, fistuloscopy helps to identify any possible secondary tracts or chronic abscesses. The VAAFT technique is sphincter-saving, and the surgical wounds are extremely small. Our preliminary results are very promising.

Endorectal advancement flap with muscular plication: a modified technique for rectovaginal fistula repair

AIM

Endorectal advancement flap is the most used treatment for acquired rectovaginal fistula but is liable to failure. We describe our experience with a modified technique.

METHOD

Patients were included who had an acquired rectovaginal fistula. Exclusions included patients with Crohn's disease with proctitis, malignant or radiation-related fistula, stricture of the anorectum or those with an external sphincter defect. Surgery included closure of the internal opening with a figure-of-eight reabsorbable suture, plication of the anorectal muscular layer and mucosal flap advancement. Total parenteral nutrition was administered postoperatively for seven days.

RESULTS

Between March 2003 and July 2008, 23 consecutive women (mean age 45.5 [28-78] years) were treated. The cause of fistulation included obstetric injury (n = 5), cryptoglandular disease (n = 11) and Crohn's disease (n = 7). Thirteen (57%) patients had a previous failed repair. At a mean follow-up of 14 (2-67) months, success was achieved in 65% (15/23) of patients. The mean Wexner incontinence scores pre- and postoperatively were 1.3 (0-15) and 0.6 (0-6), respectively.

CONCLUSION

The success rate was promising with no deterioration of anal continence.

Is the outcome of transanal advancement flap repair affected by the complexity of high transsphincteric fistulas?

BACKGROUND

Transanal advancement flap repair for the treatment of high transsphincteric fistulas fails in 1 of every 3 patients. Until now no definite risk factors for failure have been identified. The question is whether the more complex fistulas, such as those with horseshoe extensions and associated abscesses, have a less favorable outcome.

OBJECTIVE

Aim of the present study was to indentify whether more complex fistulas have a less favorable outcome.

DESIGN

This study is a retrospective case series review.

PATIENTS

Between 1995 and 2007 a series of 162 patients underwent endoanal MR imaging before transanal advancement flap repair. Two investigators, without prior knowledge of the surgical findings, reviewed all MR images.

RESULTS

Lateral fistulas were identified in 5 patients. Because of the small number, these patients were excluded from further analysis. Posterior fistulas were identified in 119 patients (76%). These fistulas had 3 types of extensions: a direct course (36%), a classic horseshoe extension (23%), or an intersphincteric horseshoe extension (41%). The corresponding healing rates were 37%, 81%, and 73%. Anterior fistulas were observed in 23% of the patients. These fistulas had 2 types of extensions: a direct course (61%) or a classic horseshoe extension (39%). The corresponding healing rates were 60% and 52%. The healing rate of fistulas with a direct course was significantly lower than the healing rate of fistulas with a classic or intersphincteric horseshoe extension. Associated abscesses were found in 47% of the posterior fistulas and 5% of the anterior fistulas. Once adequately drained, these abscesses did not affect the outcome of transanal advancement flap repair.

CONCLUSION

The complexity of high transsphincteric fistulas does not affect the outcome of transanal advancement flap repair.

Obesity is a negative predictor of success after surgery for complex anal fistula

Background

It was the aim of this study to compare the outcome of surgery for complex anal fistulas in obese and non-obese patients.

Methods

All patients with complex anorectal fistulas who underwent fistulectomy and/or rectal advancement flap repair were prospectively recorded. Surgery was performed in a standardized technique. Body mass index (BMI [kg/m²]) was used as objective measure to indicate morbid obesity. Patients with a BMI greater than 30 were defined as obese, and patients with a BMI below 30 were defined as non-obese. The parameters analyzed related to BMI included success or failure, and reoperation rate due to recurrent abscess. Success was defined as closure of both internal and external openings, absence of drainage without further intervention, and absence of abscess formation.

Results

Within two years, 220 patients underwent advancement flap repair and met the inclusion criteria. 55% of patients were females, mean age was 39 (range 18-76) years, and the majority of fistulas were located at the posterior site. 69% of patients (152/220) were non-obese (BMI < 30), whereas 31% (68/220) were obese (BMI > 30). After a median follow-up of 6 months, primary healing rate ("success") for the whole collective was 82% (180/220). Success was significantly different between non-obese and obese patients: In non-obese patients, recurrence rate was significantly lower than in obese patients (14% vs. 28%; p < 0.01). Moreover, reoperation rate due to recurrent abscess with the need for seton drainage in the failure groups was significantly higher in obese patients when compared to non-obese patients (73% vs. 52%; p < 0.01). Using multivariate analysis, obesity was identified as independent predictive factor of success or failure (p < 0.02).

Conclusion

Obese patients are at higher risk for failure after surgery for complex anal fistula.

Treatment of complex fistula in ano with cable-tie seton: a prospective case series

Objective. To determine the fecal incontinence and recurrence rate in patients with complex fistula in ano managed with cable tie seton at a tertiary care teaching hospital. Methods. This is a prospective case series of patients with complex anal fistula i.e. recurrent fistula or encircling >30% of external anal sphincter, managed with cable tie seton from March 2003 to March 2009. Patients were seen in the clinic after 72 hours of seton insertion under anesthesia and then every other week. Each time the cable-tie was tightened if found loose without anesthesia and incontinence was inquired according to wexner's score. Results. Seventy nine patients were treated during the study period with the age (mean ± standard deviation) of 41 ± 10.6 years and. The seton was tightened with a median of six times (3–15 times range). Complete healing was achieved in 11.2 ± 5.7 weeks. All the patients were followed for a minimum period of one year and none of the patients had any incontinence. Recurrence was found in 4 (5%) patients. Conclusion. The cable tie seton is safe, cost effective and low morbidity option for the treatment of complex fistulae-in-ano. It can, therefore, be recommended as the standard of treatment for complex fistulae-in-ano requiring the placement of a seton.

Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin

BACKGROUND

Closure of rectoanovaginal fistula from a cryptoglandular or obstetrical origin can be difficult. Multiple techniques exist and none are perfect. Although episioproctotomy offers the advantage of a simultaneous repair of the sphincter complex, it is a more extensive procedure. A rectal-advancement flap appears less traumatic and divides no perineal tissue or sphincter. The aim of this study was to evaluate the results of episioproctotomy and rectal-advancement flap on healing, postoperative continence, and sexual function.

METHODS

Data were retrospectively collected regarding 87 women with cryptoglandular or obstetrical rectoanovaginal fistula treated from June 1997 to 2009, who underwent episioproctotomy or rectal-advancement flap at the discretion of the treating surgeon. Healing, use of seton or stoma, number of previous procedures, smoking, age, body mass index, dyspareunia, SF-12 health survey, the IBD Quality of Life, and the Fecal Incontinence Quality of Life, and the Female Sexual Function Index were obtained from our database and via telephone interviews. The Fisher exact probability and χ tests were used.

RESULTS

The mean age of these 87 women was 42.8 ± 10.5 years. Mean follow-up was 49.2 ± 39.2 months. Fifty (57.5%) patients underwent episioproctotomy and 37 (42.5%) underwent rectal-advancement flap. Thirty-nine (78%) patients healed after episioproctotomy vs 23 (62.2%) patients after rectal-advancement flap (P = .1). Episioproctotomy was associated with significantly better fecal (P < .001) and sexual (P = .04) function. There was no significant difference in other studied variables between the 2 techniques.

CONCLUSIONS

Despite episioproctotomy being a more extensive procedure, healing rates were comparable between episioproctotomy and rectal-advancement flaps. In this select population, episioproctotomy may provide better continence and may confer better sexual function compared with rectal-advancement flap. In appropriate patients surgeons should not hesitate to perform episioproctotomy on cryptoglandular or obstetrical-associated rectoanovaginal fistula.

Review article: medical, surgical and radiological management of perianal Crohn's fistulas

BACKGROUND

Crohn's anal fistulas are common and cause considerable morbidity. Their management is often difficult; medical and surgical treatments rarely lead to true healing with frequent recurrence and complications.

AIM

To examine medical treatments previously and currently used, surgical techniques and the important role of optimal imaging.

METHODS

We conducted a literature search in the Pub Med database using Crohn's, Anal Fistula, Surgery, Imaging and Medical Treatment as search terms.

RESULTS

Antibiotics and immunosuppressants have a role, but slow initial response, side effects and relatively low remission rates of up to around a third with frequent recurrence limit their value. Long-term infliximab produces clinical remission in 36-58% of patients with combined medical and surgical management achieving optimal outcomes. Traditional and newer surgical procedures often have a high rate of recurrence with a significant risk of temporary or, in up to 10% of cases, permanent stomas, incontinence and unhealed or slowly healing wounds in 30%.

CONCLUSIONS

Management of Crohn's anal fistulas remains challenging. Established principles are to drain infection, use setons as required, aggressively manage active proctitis, give antibiotics, immunosuppressants and employ anti-TNFα therapy, and they demand significant co-operation between gastroenterologists and surgeons.

Sphincter-preserving fistula management: what patients want

PURPOSE

The purpose of this study was to determine how patients with anal fistulas would rank clinical scenarios describing various management options for anal fistulas.

METHOD

A survey was administered to 74 consecutive patients with anal fistulas. On each survey, 10 clinical scenarios describing various treatment options for anal fistulas were scored from 1 (most likely to select) to 10 (least likely to select). Mean scores for each scenario were calculated and compared by use of a Student t test.

RESULTS

When combined, 74% of patients selected a sphincter-preserving technique as their primary choice compared with 26% who chose a fistulotomy (P < .0001). Compared with the highest ranking sphincter-preserving techniques, the mean scores of the scenarios involving a fistulotomy were significantly (P < .05) lower (less likely to select). The mean score of a traditional fistulotomy was the same as the mean score of a sphincter-preserving technique with a 50% success rate but no risk of diminished continence.

CONCLUSIONS

These data suggest that the majority of patients with an anal fistula will select a sphincter-preserving technique to manage their fistula. This finding may indicate that, within limits, it is of greater importance for most patients to minimize their risk of diminished continence than to have a highly successful treatment strategy for their fistula.

A systematic review on advancement flaps for rectovaginal fistula in Crohn's disease: transrectal vs transvaginal approach

AIM

Despite advances in the treatment of Crohn's disease (CD), the treatment of rectovaginal (RV) fistula remains challenging. Transrectal (RAF) and transvaginal advancement flaps (VAF) represent two possible alternative surgical approaches to this problem. The study aims to review and compare the results of these approaches for RV fistula in CD.

METHOD

Medical databases from January 1983 to August 2008 were consulted for potentially relevant publications. All studies dealing with the RV fistula repair in CD with RAF or VAF were included. Two researchers worked independently on the study selection, quality assessment, data extraction and analysis phases of the study. Analyses were performed with Review Manager 2.0 software.

RESULTS

Eleven observational studies were included with a total of 219 flap procedures for RV fistula. The primary fistula closure pooled rate was 54.2% (range 33.3-100%) after RAF and 69.4% (range 0-92.9%) after VAF (P = 0.13). Four studies were eligible for direct comparison between the two procedures. No clearly significant difference between RAF compared with VAF in terms of primary fistula closure rate, nor in terms of overall fistula closure rate, was apparent. The risk of recurrence after RAF compared with VAF seemed similar; in this case, only two studies were taken into consideration.

CONCLUSIONS

Although limited by a small number of studies of low clinical evidence level, this systematic review suggests that there is no significant difference in terms of outcome between RAF and VAF for RV fistula in CD.

Seton drainage prior to transanal advancement flap repair: useful or not?

INTRODUCTION

Transanal advancement flap repair (TAFR) provides a useful tool in the treatment of high transsphincteric fistulas. Recent studies indicate that TAFR fails in one out of three patients. Until now, no definite predictive factor for failure has been identified. Although some authors have reported that preoperative seton drainage might improve the outcome of TAFR, this could not be confirmed by others. We conducted the present study to assess the influence of preoperative seton drainage on the outcome of TAFR in a relatively large series.

METHODS

Between December 1992 and June 2008, a consecutive series of 278 patients [M/F = 179:99, median age 46 years (range, 19-73 years)] with cryptoglandular, transsphincteric fistula, passing through the upper or middle third of the external anal sphincter underwent TAFR. Patients were recruited from the colorectal units of two university hospitals (Erasmus Medical Center, Rotterdam, n = 211; and Leiden University Medical Center, Leiden, n = 67). Baseline characteristics did not differ between the two clinics. Sixty-eight of these patients underwent preoperative seton drainage for at least 2 months and until the day of the flap repair.

RESULTS

Median healing time was 2.2 months. In patients without preoperative seton drainage, the healing rate was 63%, whereas the healing rate was 67% in patients who underwent preoperative seton drainage. This difference was not statistically significant. No differences in healing rates were found between the series from Leiden and Rotterdam.

CONCLUSION

Preoperative seton drainage does not improve the outcome of TAFR.

The efficacy of anal fistula plug in fistula-in-ano: a systematic review

AIMS

To assess the efficacy of anal fistula plug (AFP) procedure for the treatment of fistula-in-ano especially the complex fistulas.

METHOD

The database of PUBMED, MEDLINE, SCOPUS, EMBASE and COCHRANE LIBRARY for the period 1995-2009 was searched. A systematic analysis was carried to evaluate the success rate of AFP procedure in fistula-in-ano.

RESULTS

A total of 25 studies were extracted and 12 (n = 317) were finally included in the systematic review. The follow-up period ranged from 3.5 to 12 months. The AFP procedure had a success rate (patient cure rate) ranging from 24% to 92%. In complex fistula-in-ano in prospective studies (8/12 studies), the success rate was 35-87%. The success rate in patients with Crohn's disease was 29-86%. The success rate in the patients with single tracts was 44-93% and in patients with multiple tracts, success ranged from 20% to 71%. The abscess formation/sepsis rate was 4-29% (11/108) and the plug extrusion rate was 4-41% (42/232-19%).

CONCLUSION

Anal fistula plug procedure has a success rate ranging from 24% to 92% in different studies. In prospective studies of complex fistula-in-ano, there was a moderate success rate of 35-87%. As AFP is associated with low morbidity and sepsis, it appears to be a safe procedure. Further randomized controlled trials studying objective parameters of fistula healing are needed to substantiate these findings.

Fibrin glue in the management of complex anal fistula

CONTEXT

Management of complex anal fistulas is associated with the risk of sphincter injury and fecal incontinence. In recent years, fibrin glue has emerged as an alternative sphincter-preserving treatment for anal fistulas. To date, however, there is no consensus about the efficacy of the method.

OBJECTIVE

To specifically evaluate the fibrin glue injection in the management of complex cryptoglandular anal fistulas.

METHODS

We studied a series of patients with complex anal fistulas treated with fibrin glue between January 2005 and January 2007. Only patients with fistulas of cryptoglandular origin were analyzed. Patients with fistulas related to Crohn's disease, HIV or previous surgery were excluded from the study. Under spinal anesthesia, the fistulas were curetted and injected with fibrin glue. After treatment, patients were followed-up for 12 months.

RESULTS

Thirty-two patients were enrolled in the study. Two patients were lost to follow-up and were excluded. Out of the remaining 30 patients, only three healed successfully (10%). Among the 27 patients who failed to heal, 9 (33.3%) were diagnosed within the first postoperative month. In 13 patients (48.1%) the failure of treatment occurred in the period between 1 and 3 months, in 3 patients (11.1%) between 3 and 6 months, and in 2 patients (7.4%) between 6 and 9 months after surgery. No treatment-related complications were observed.

CONCLUSIONS

In this series, fibrin glue treatment for complex cryptoglandular anal fistulas achieved a very low healing rate. Our results do not support the use of fibrin glue as a first-line treatment for patients with this type of fistula.

Long-term outcomes with the use of bioprosthetic plugs for the management of complex anal fistulas

PURPOSE

This study was undertaken to determine the long-term outcomes of patients whose anal fistulas were managed by use of bioprosthetic plugs.

METHOD

A retrospective analysis was performed of all patients whose anal fistula was managed by use of a bioprosthetic plug between May 2005 and September 2006, who had a minimum of 1 year of follow-up since their last treatment. Patients whose fistulas were clinically healed were offered MRI to confirm healing of the fistula.

RESULTS

The bioprosthetic fistula plug was used to treat an anal fistula in 63 patients with clinical healing of the fistula in 51 (81%). Multivariate analysis showed that tobacco smoking, posterior fistula, and history of previous failure of the bioprosthetic plug was predictive of failure of the bioprosthetic plug. Eight patients with clinical healing after a minimum of 1 year since their last treatment underwent MRI. No evidence of residual fistula tract or fluid in the area of the previous fistula was found in 6 (75%) of these patients.

CONCLUSION

Bioprosthetic plugs are effective for the long-term closure of complex fistulas-in-ano. Randomized clinical trials comparing bioprosthetic plugs with other sphincter-preserving methods for fistula management need to be conducted to further determine the role of bioprosthetics in the management of anal fistulas.

A retrospective review of chronic anal fistulae treated by anal fistulae plug

OBJECTIVE

The aim of this study was to analyse the efficacy of the anal fistulae plug (Cook Surgisis AFP) for the management of complex anal fistulae.

METHOD

A review of patients with anal fistulae treated using Cook Surgisis AFP between October 2005 and 2007 was undertaken. Patient's demographics, fistulae aetiology and success rates were recorded.

RESULTS

Thirty-three patients underwent 49 plug insertions. The median age was 44.4 years; 18 females. The fistulae aetiology was cryptoglandular in 61% and Crohn's disease in 39%. The median follow up 221.5 days (range 44-684). Twenty-one patients had previous failed surgery. Twenty-eight patients had draining setons in situ at time of plug placement. The overall success rate was 8/32 patients (25%). Two of the 22 Crohn's fistulae healed (9.1%) and 9/26(34.6%) cryptoglandular fistulae healed. The reasons for failure were sepsis in 87% and plug dislodgement in 13%. Significant predictor factors for improved outcome were African-Americans patients (P = 0.009), and presence of seton (P = 0.05).

CONCLUSIONS

Anal fistulae plug was associated with a lower success rate than previously reported. Septic complications were the main reason for failure.

Perianal fistulae in Crohn's Disease: current and future approaches to treatment

: affecting sphincter integrity and continence. Traditional surgical and medical approaches are not without their limitations and may result in either comorbidity, such as fecal incontinence, or incomplete healing of the fistulae. Over the last 2 decades these limitations have led to a paradigm shift toward the use of biomaterials, and more recently cell-based therapies, which have met with variable degrees of success. This review discusses the traditional and current methods of treatment, as well as emerging and possible alternative approaches that may improve fistula healing.

Endorectal advancement flap for cryptoglandular or Crohn's fistula-in-ano

PURPOSE

Objectives of surgical treatment for transsphincteric and complex anorectal fistulas are the successful elimination of current/recurrent disease and the preservation of sphincter function. The concept of endorectal advancement flaps is to preserve the sphincter by closing off the primary opening by means of a mobilized flap. We performed a systematic review of the literature to assess the role of this technique.

METHODS

A literature search on transanal rectal advancement flaps to treat cryptoglandular or Crohn fistula-in-ano was performed for the 30-year period between 1978 and 2008. Rectovaginal/rectourinary or cancer-related fistulas were excluded. Each study was examined for length of follow-up and the 2 major end points: success rate and incontinence rate.

RESULTS

From 35 studies with 2065 patients, we identified 1654 patients undergoing endorectal advancement flaps for cryptoglandular or Crohn disease. Four hundred eleven subjects were excluded (319 rectovaginal/rectourinary fistulas; 92 other causes). The quality of the reports was limited (low-level evidence) with numerous structural and design flaws. Weighted success and incontinence rates were 80.8%/13.2% for cryptoglandular and 64%/9.4% for Crohn fistulas.

CONCLUSION

Endorectal advancement flap is one tool, although not a perfect one, to treat complex anorectal fistulas of cryptoglandular or Crohn origin. Higher level evidence would be needed for comparison with other surgical techniques.

Risk factors for recurrence and incontinence after anal fistula surgery

OBJECTIVE

Fistula-in-ano continues to raise problems that require important therapeutic decisions. Our aim was to evaluate its recurrence and incontinence risk factors.

METHOD

We analysed a series of 279 patients who had undergone anal fistula surgery with long-term follow-up.

RESULTS

42.7% of the fistulae were considered complex and 46% had been referred from other institutions. There was delayed healing or recurrence in 7.2% patients, which appeared at a median of 4 months. The factors associated with recurrence were the type of fistula (extrasphincteric/suprasphincteric), nonidentification of internal opening (IO), recurrent or complex fistulae (CF), and associated chronic abscess. Only CF and nonidentification of IO were statistically significant in the multivariate analysis. Preoperative incontinence was a risk factor for postoperative incontinence, as were suprasphincteric, recurrent and CF. The age and gender of the patient did not influence postoperative continence, nor did the surgeon or surgical technique appear as a risk factor, although after excluding preoperative incontinent patients, fistulotomy was the technique that showed a higher risk of incontinence. Multivariate analysis only confirmed previous incontinence as a RF.

CONCLUSION

The overall recurrence rate is acceptable, but high fistulae continue to be difficult to treat. IO identification is also essential for obtaining good results. It is important to identify the patients with preoperative incontinence as they are at a greater risk of deterioration after surgery.

Ligation of the intersphincteric fistula tract (LIFT): a sphincter-saving technique for fistula-in-ano

PURPOSE

This study was designed to assess the total anal sphincter-saving technique of ligating the intersphincteric fistula tract for the treatment of fistula-in-ano.

METHODS

We performed a prospective observational study of patients with fistula-in-ano treated with the ligation of the intersphincteric fistula tract technique from May 2007 through September 2008. All patients had fistulas arising from cryptoglandular infections. Recurrence rate, healing time, and morbidities related to the procedure were determined with a standard follow-up protocol.

RESULTS

Forty-five patients with transsphincteric (n = 33) or complex (n = 12) fistulas were included in the study. Five patients (11.1%) had recurrent fistula-in-ano after prior surgery using other recognized treatment procedures. The median age was 41.5 (range, 27-56) years; median follow-up, 9 (range, 2-16) months. Primary healing was achieved in 37 patients (82.2%), with a median healing time of 7 (range, 4-10) weeks. Eight patients (17.7%) had recurrence of fistula between 3 and 8 months after the operation. No clinically significant morbidity was noted in any of the 45 patients.

CONCLUSIONS

The ligation of the intersphincteric fistula tract technique for fistula-in-ano surgery, which aims at total anal sphincter preservation, appears to be both safe and easy to perform, with encouraging early outcomes.

Outcome of surgery for rectovaginal fistula due to Crohn's disease

BACKGROUND

This study examined the outcome of surgery for symptomatic Crohn's rectovaginal fistula (RVF) and assessed the effect of therapy with antibody against tumour necrosis factor (TNF) on healing.

METHODS

Fifty-six patients with Crohn's disease underwent surgery for a RVF between January 1993 and December 2006. Outcome analysis was performed in February 2008 in relation to the surgical procedures used and the effect of anti-TNF treatment.

RESULTS

Four patients with a healed fistula still had a stoma at final follow-up for other reasons and were excluded from the analysis. Fistula closure was achieved in 81 per cent of the remaining 52 patients. Primary and secondary surgical success rates were 56 and 57 per cent respectively. The primary healing rate was similar in patients who received anti-TNF treatment before the first operation (12 of 18 patients) and those who did not (19 of 34). In univariable analysis, duration of Crohn's disease (P = 0.037) and previous extended colonic resection (P < 0.001) were significantly related to failure of primary surgery, but only the latter remained significant in multivariable analysis (P < 0.001). Late recurrence developed in four patients.

CONCLUSION

Fistula closure was achieved in most patients, but more than one operation was often required.

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.

Required length of follow-up after transanal advancement flap repair of high transsphincteric fistulas

OBJECTIVE

Repair of high perianal fistulas presents a major surgical challenge. Transanal advancement flap repair (TAFR) provides a useful tool in the treatment of these fistulas. Initially promising results have been reported. More recent studies indicate that TAFR fails in one out of three patients. The aim of the present study was to determine the appropriate length of follow-up needed to assess the healing rate after TAFR of high transsphincteric fistulas.

METHOD

Between 1992 and 2000 a consecutive series of 80 patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Medical records of all patients were studied. The initial healing rate and the median healing time were assessed. The initial outcome was successful in 54 patients. The medical records revealed that only one of these patients presented with a recurrent fistula after 28 months. The other 53 patients were sent a questionnaire in 2006 aimed to determine whether they had any complaints or signs of a recurrent fistula.

RESULTS

The initial healing rate was 68%. The median healing time was 3.6 months. The completed questionnaire was returned by 48 patients. None of these patients reported any complaints or signs of a recurrent fistula. Median duration of follow-up in these patients was 92 months.

CONCLUSION

At a median time interval of 3.6 months fistula healing was observed in 54 patients (68%). Only one patient (2%) encountered a recurrence. The length of follow-up can be restricted to the healing time.

Does rectal mucosal blood flow affect the outcome of transanal advancement flap repair?

INTRODUCTION

Transanal advancement flap repair provides a useful tool for the treatment of high transsphincteric fistulas. Recent studies indicate that transanal advancement flap repair fails in one of every three patients. Until now no definite risk factors for failure have been identified. A previous pilot study, conducted in our own institution, revealed a significant decrease in rectal mucosal blood flow after creation of the advancement flap. We postulated that impaired blood flow might result in breakdown of the distal part of the flap. This study was designed to evaluate the effect of rectal mucosal blood flow on the outcome of transanal advancement flap repair.

METHODS

Between August 2004 and June 2007 a series of 54 patients with a high transsphincteric fistula underwent transanal advancement flap repair. The present series comprised 34 males and 20 females. Median age at the time of repair was 45 (range, 25-68) years. Rectal mucosal blood flow was determined by laser Doppler flowmetry before and after creation of the flap. The flow was expressed in arbitrary units.

RESULTS

Transanal advancement flap repair was successful in 34 patients (63%). Median healing time was 2.2 months. Median mucosal blood flow before and after transanal advancement flap repair was 145 arbitrary units and 94 arbitrary units, respectively. This decrease was statistically significant. In a comparison of patients with and patients without a successful repair, no differences were found in mucosal blood flow before and after creation of the flap (146 vs. 138 arbitrary units and 83 vs. 104 arbitrary units).

CONCLUSION

Rectal mucosal blood flow does not affect the outcome of transanal advancement flap repair.

To determine the efficacy of anal fistula plug in the treatment of high fistula-in-ano: an initial experience

OBJECTIVE

The aim of this study was to determine the efficacy of the anal fistula plug in the treatment of high fistula-in-ano.

METHOD

Twenty-three patients with high cryptoglandular fistula-in-ano were prospectively studied over 1 year. The number of tracks, number of previous procedures and co-morbid conditions that could potentially affect outcome were noted. A seton was used to guide the AFP into the fistula track which was anchored at the primary opening.

RESULTS

Two patients were lost to follow-up. Twenty-one patients (mean age was 49.8 years) were followed from 192 to 543 days (median = 292 days). Thirteen patients had single track, eight had multiple tracks and 14 had a recurrent fistula. Success, defined by closure of all fistula tracks occurred in 71.4% (15/21). The success rate was 84.6% in patients with a single fistula track (11/13) compared with 50% in patients with multiple tracks (4/8) (P = 0.14, Fisher's exact test). Recurrent [10/14 (71.4%)] vs nonrecurrent fistulae [5/7 (71.4%)] had no bearing on the outcome (P = 1.0). Two patients experienced healing despite extrusion of the plug in the early postoperative period. The procedure was safe and well tolerated.

CONCLUSION

The Surgisis AFP was successful in 71.4% of patients. Plug extrusion does not necessarily mean failure.

Outcome of surgical treatment for fistula in ano in Crohn's disease

BACKGROUND

Recurrence rates and long-term functional outcome after surgical treatment of anal fistula in Crohn's disease were assessed.

METHODS

A consecutive series of patients was treated for Crohn's fistula in ano; those without proctitis or active sepsis underwent surgery. Sex, seton usage, infliximab, previous fistula surgery, history of segmental resection and smoking were examined as risk factors for recurrence. Continence was assessed by Vaizey scale and a colorectal Functional outcome questionnaire. Results were compared with institutional data for cryptoglandular fistulas.

RESULTS

Sixty-one patients were included, with a median follow-up of 79 (range 13-140) months. Twenty-four patients were treated with a seton, 28 by fistulotomy and nine by mucosal advancement. For low fistulas, fistulotomy was used more frequently than the seton, whereas seton drainage was used for most higher fistulas. Recurrence occurred in five of 28 and five of nine patients after fistulotomy and advancement respectively. Soiling was reported by half of the patients treated by seton versus two-thirds and three-quarters of those treated by fistulotomy and advancement respectively. Functional outcomes were worse for all patient groups than for cryptoglandular fistulas. No risk factor was significant.

CONCLUSION

Surgical outcome for high or complex Crohn's fistula in ano remains disappointing, and recurrence is unpredictable.

Preliminary results on efficacy in closure of transsphincteric and rectovaginal fistulas associated with Crohn's disease using new biomaterials

BACKGROUND AND AIMS

It was the aim of this prospective study to analyze the efficacy of the Surgisis AFP anal fistula plug and the Surgisis mesh for the closure of complex fistulas in Crohn's disease.

METHODS

All patients with perianal Crohn's disease suffering from transsphincteric and rectovaginal fistulas who underwent surgery using the Surgisis anal fistula plug or the Surgisis mesh were prospectively enrolled in this study. Inclusion criteria included transsphincteric single-tract fistulas and rectovaginal fistulas. Surgery was performed using a standardized technique, including irrigation of the fistula tract, placement and internal fixation of the Surgisis anal fistula plug, and combined transanal/transvaginal excision of rectovaginal fistula with transvaginal placement of the mesh. Success was defined as closure of both internal and external (perianal or vaginal) openings, absence of drainage without further intervention, and absence of abscess formation. Follow-up information was obtained from clinical examination 3, 6, 9, and 12 months postoperatively.

RESULTS

Within the observation period, a total of 16 procedures were performed. After a mean follow-up of 9 months and 1 patient lost to follow-up, the overall success rate was 75%. For transsphincteric fistulas, the success rate was 77%, whereas it was 66% in rectovaginal fistulas associated with Crohn's disease. All 4 patients with failure had reoperation. Rate of stoma reversal in those patients who had fecal diversion was 66%. No deterioration of continence was documented.

CONCLUSION

The short-term success rates are promising. Further analysis is needed to explain the definite role of this technique in comparison with traditional surgical techniques.

Innovative technique for the closure of rectovaginal fistula using Surgisis mesh

BACKGROUND

The aim of this prospective study was to analyse the efficacy of Surgisis mesh for closure of rectovaginal fistulas. Prospective data were collected from two centres.

METHODS

All patients with a rectovaginal fistula who underwent definitive surgery using Surgisis mesh were prospectively enrolled in this study. Inclusion criteria included a rectovaginal fistula in the lower two-thirds of the rectovaginal septum. Surgery was performed with a standardized technique including combined transrectal and transvaginal excision of the rectovaginal fistula with transvaginal placement of the mesh. Success was defined as closure of both internal and external (perianal and vaginal) openings, absence of drainage without further intervention, and no abscess formation.

RESULTS

Over a period of 16 months, a total of 21 mesh procedures were performed in two centres. The mean age of the patients was 47 years (18-59 years). Of the 21 patients, 18 (86%) had recurrent rectovaginal fistula, and the mean number of prior attempts was 2.3 (0-8). The majority of patients (nine) had Crohn's disease-associated fistula, followed by six with iatrogenic fistula, two with radiation-induced fistula, two with obstetric injury-induced fistula, and two with idiopathic fistula. The mesh procedure was performed under faecal diversion in eight patients (38%). The mean operative time was 38 min; no intraoperative morbidity occurred. Patients were discharged from hospital on day 4. After a mean follow-up of 12 months (range, 3-18 months), the overall success rate after primary mesh procedure was 71% (15/21; 6 patients had failure or recurrence). All patients with failure or recurrence were reoperated upon. Out of these six patients who were reoperated upon, four had definite healing (75%). Among the eight patients who had faecal diversion, four (50%) had reversal of their stoma.

CONCLUSION

The preliminary success rate for this innovative technique using Surgisis mesh for the closure of rectovaginal fistulas is promising. Further studies are needed to assess the definite role of this novel technique in comparison to traditional surgical procedures.

Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn's disease

BACKGROUND

Due to the considerable variety in the clinical presentation of anorectal and rectovaginal fistulas in Crohn's disease, data on treatment results for each type of fistula are limited. The aim of this study was to summarize the results after surgical treatment of such fistulas in a large consecutive series of patients.

PATIENTS AND METHODS

All patients with anorectal or rectovaginal fistula due to Crohn's disease requiring surgery in our institution between 1991 and 2001 were extracted from a prospective database. A standardized telephone interview was conducted and patients were followed in our outpatient clinic, the department of internal medicine, or at their gastroenterologist. Type of fistula and interventions were classified and analyzed. Recurrence-free time intervals were estimated for each type of fistula and for the different surgical procedures. The influence of the surgical procedure, the number of operations performed, and the correlation to other localizations of the disease were analyzed in regard to the recurrence rate.

RESULTS

From 777 patients with Crohn's disease undergoing surgery between 1991 and 2001, 147 had anorectal or rectovaginal fistula (292 operations). Ninety-eight percent of them also had Crohn's disease in the colon or rectum compared to only 21% of patients without a fistula (p value <0.001). Over long-term follow-up, 29 patients (20%) required proctectomy. Submucosal fistulas needed major surgery in only 14% of cases compared to 56% of cases with rectovaginal fistulas. After 5 years, complex fistulas showed a strong trend towards a higher recurrence rate after surgery than simple submucosal fistulas (45.6% vs. 18.8%, p = 0.079). Whereas recurrences occurred over the whole observation period in the group of patients with complex fistulas, there was no further recurrence in patients with submucosal fistulas 13 months after surgery. In rectovaginal fistulas, additional levatorplasty showed no advantage over standard endorectal advancement flap.

CONCLUSIONS

Long-term follow-up demonstrates that recurrence rates after repair of complex fistulas for Crohn's disease are high and continuously increase over time. Submucosal fistulas have the best outcome; after 13 months without recurrence, definite cure can be expected.

Treatment of transsphincteric anal fistulas: are fistula plugs an acceptable alternative?

PURPOSE

Treatments for transsphincteric, cryptoglandular anal fistulas pose risks for high recurrence rates and impaired anal continence. Anal fistula plugs have gained popularity because of reports of success without compromising the anal sphincter. To examine the benefit of the anal fistula plug, we compared its success rate with a standard treatment for transsphincteric fistulas with similar indications, the transanal mucosal advancement flap.

METHODS

We examined the outcomes of all patients with transsphincteric fistulas who underwent anal fistula plug repair from July 2005 to December 2006, excluding those with Crohn's disease or less than three months of follow-up. They were compared with a historical control group of patients (2001-2005) with similar transsphincteric fistulas who underwent a transanal mucosal advancement flap procedure because the anal fistula plug was not available. The same surgeons performed both procedures. Outcome was assessed from medical records or telephone follow-up.

RESULTS

Twenty-nine patients underwent an anal fistula plug repair, and 26 patients underwent a flap procedure. Fistula closure rates were 34 percent for plugs and 62 percent for flaps (P = 0.045). The groups were similar in all respects except that 3 percent of plug patients and 58 percent of flap patients had postoperative inpatient stays and the median follow-up was longer (279 vs. 819 days) for the flap group.

CONCLUSION

Fistula closure rates were significantly lower with anal fistula plugs than with advancement flaps. Although the low success rates for fistula plugs could be a result of patient selection, more data needs to be accrued before fistula plugs can be recommended as definitive first-line treatment for transsphincteric fistulas.

Anal fistula plug: initial experience and outcomes

PURPOSE

This study was designed to analyze the efficacy of the Cook Surgisis AFP anal fistula plug for the management of complex anal fistulas.

METHODS

This was a retrospective review of all patients prospectively entered into a database at our institution who underwent treatment for complex anal fistulas using Cook Surgisis AFP anal fistula plug between July 2005 and July 2006. Patient's demographics, fistula etiology, and success rates were recorded. The plug was placed in accordance with the inventor's guidelines. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation.

RESULTS

Thirty-five patients underwent 39 plug insertions (22 men; mean age, 46 (range, 15-79) years). Three patients were lost to follow-up, therefore, 36 procedures to be analyzed. The fistula etiology was cryptoglandular in 31 (88.6 percent) patients and Crohn's disease associated in the other 4 (11.4 percent). There were 11 smokers and 3 patients with diabetes. The mean follow-up was 126 days (standard = 69.4). The overall success rate was 5 of 36 (13.9 percent). One of the four Crohn's disease-associated fistulas healed (25 percent) and 4 of 32 (12.5 percent) procedures resulted in healing of cryptoglandular fistulas. In 17 patients, further procedures were necessary as a result of failure of treatment with the plug. The reasons for failure were infection requiring drainage and seton placement in 8 patients (25.8 percent), plug dislodgement in 3 (9.7 percent), persistent drainage/tract and need for other procedures in 20 patients (64.5 percent).

CONCLUSIONS

The success rate for Surgisis AFP anal fistula plug for the treatment of complex anal fistulas was (13.9 percent), which is much lower than previously described. Further analysis is needed to explain significant differences in outcomes.

Diagnosis and management of fistulizing Crohn's disease

The transmural inflammation characteristic of Crohn's disease predisposes patients to the formation of fistulas. Up to 50% of patients with Crohn's disease are affected by fistulas, which is a major problem given the considerable morbidity associated with this complication. Appropriate treatment of fistulas requires knowledge of specific pharmacological and surgical therapies. Treatment options depend on the severity of symptoms, fistula location, the number and complexity of fistula tracts, and the presence of rectal complications. Internal fistulas, such as ileoileal or ileocecal fistulas, are mostly asymptomatic and do not require intervention. By contrast, perianal fistulas can be painful and abscesses may develop that require surgical drainage with or without seton placement, transient ileostomy, or in severe cases, proctectomy. This Review describes the epidemiology and pathology of fistulizing Crohn's disease. Particular focus is given to external and perianal fistulas, for which treatment options are well established. Available therapeutic options, including novel therapies, are discussed. Wherever possible, practical and evidence-based treatment regimens for Crohn's disease-associated fistulas are provided.

Treatment of transsphincteric anal fistulas by endorectal advancement flap or collagen fistula plug: a comparative study

PURPOSE

In this study we compared the outcomes of patients with complex cryptoglandular fistulas treated by endorectal advancement flap or anal fistula plug.

METHODS

We performed a retrospective analysis of patients with transsphincteric anal fistulas treated by endorectal advancement flap or anal fistula plug from January 1996 through April 2007. Patients with noncryptoglandular fistulas or insufficient follow-up were excluded. Results were obtained with a combination of chart reviews, mailed questionnaire, and phone interviews. Success was defined as a closed external opening in absence of symptoms at a minimal follow-up time of six months.

RESULTS

Forty-three patients had an endorectal advancement flap and 37 patients had an anal fistula plug procedure. The two cohorts were comparable for age, gender, smoking status, fistula type, and previous failed treatments. The success rate was 63 percent in the endorectal advancement flap group and 32 percent in the anal fistula plug group (P = 0.008), after a mean follow-up of 56 (range, 6-136) months for endorectal advancement flap and 14 (range, 6-22) months for anal fistula plug.

CONCLUSIONS

The current study indicates that the endorectal advancement flap provides a higher success rate than the anal fistula plug. Randomized trials are needed to further elucidate the efficacy and potential functional benefit of the anal fistula plug in the treatment of complex anal fistulas.

Early experience with the bioabsorbable anal fistula plug

PURPOSE

Management of anal fistula represents a balance between curing the condition and maintaining anal continence. Recent reports of the results of the porcine anal fistula plug have demonstrated excellent fistula healing rates without reporting significant complications.

METHODS

The outcome of patients who underwent treatment for anal fistula with the Surgisis anal plug was retrospectively reviewed.

RESULTS

Twenty patients were treated; three underwent concomitant anal advancement flap at the time of plug placement. Seventeen patients had a trans-sphincteric fistula, and three had an anoperineal fistula. Ten patients had previously undergone failed surgical therapy to cure their fistula, including anal advancement flap in four, muscle interposition flap in two, fistulotomy in two, and cutting seton placement in two. Mean follow-up was 7.4 months. Only 4 of 17 (24%) patients treated with the plug alone had closure of their fistula. Acute postoperative sepsis was seen in 5 of 17 (29%) patients treated with the plug alone. Four developed perianal abscesses that required incision and drainage, and one intersphincteric abscess was treated with antibiotics. Two of the patients who underwent concomitant anal advancement flaps and plug placement healed successfully.

CONCLUSIONS

Contrary to other published series, the use of the Surgisis anal plug was associated with a low rate of fistula healing and a high incidence of perianal sepsis. The addition of a transanal advancement flap to the procedure may improve success rates.

Long-term functional outcome and risk factors for recurrence after surgical treatment for low and high perianal fistulas of cryptoglandular origin

PURPOSE

This study assessed long-term functional outcome and explored risk factors for fistula recurrence in patients surgically treated for cryptoglandular fistulas.

METHODS

Three hundred ten consecutive patients were surgically treated for perianal fistulas. After exclusion of patients with inflammatory bowel disease or HIV, 179 patients remained. Patients were divided into two groups: those who received fistulotomy for low perianal fistulas and those who received rectal advancement flap for high perianal fistulas. Time to fistula recurrence was the main outcome and Cox proportional hazard models were used to assess the importance of various risk factors. Functional outcome was assessed using the Vaizey and colorectal functional outcome (COREFO) questionnaires.

RESULTS

The median follow-up duration was 76 months (range, 7-134). The 3-year recurrence rate for low perianal fistulas treated by fistulotomy (n = 109) was 7 percent (95 percent confidence interval, 1-13 percent). In high transsphincteric fistulas treated by rectal advancement flap (n = 70), the recurrence rate was 21 percent (95 percent confidence interval, 9-33 percent). In both groups, soiling was reported at 40 percent. None of the seven potential risk factors examined were statistically significant.

CONCLUSIONS

Fistula recurrence rate after fistulotomy was low. No clear risk factors were found. Overall functional outcome in terms of continence was good. However, a substantial amount of patients reported soiling.