Anocutaneous advancement flap closure of high anal fistulas

Efficacy and Safety of Sphincter-Preserving Surgery in the Treatment of Complex Anal Fistula: A Network Meta-Analysis

Background

There are many surgical methods of sphincter preservation in treating complex anal fistula, but the therapeutic effects of each operation are different. Therefore, this study aimed to compare the impact of other treatment methods through a network meta-analysis to evaluate the best sphincter preservation method for treating complex anal fistula.

Methods

We searched PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Journal Database, and the Wanfang Database to collate randomized controlled trials on sphincter-preserving surgery for complex anal fistula.

Results

A total of 29 articles were included in this meta-analysis. The cure rates showed no statistically significant differences between any two interventions (P > 0.05). The recurrence rate results showed that the rate of patients after Fistulectomy was higher than others (P < 0.05). The incidence rate of complications showed that the incidence rate after fistulectomy treatment was higher than that of others (P < 0.05). The surface under the cumulative ranking (SUCRA) was used to arrange their advantages and disadvantages, and a larger SUCRA value indicates that the intervention may be more effective. The results showed that TROPIS may have the highest cure rate (SUCRA = 78.6%), stem cell transplantation (SCT) may have the lowest recurrence rate (SUCRA = 85.5%), and imLIFT may have the least complications (SUCRA = 88.2%).

Conclusion

According to the existing literature data, for patients with complex anal fistula, TROPIS may be the surgical method with the highest cure rate, SCT may be the treatment method with the lowest recurrence rate, and imLIFT may be the surgical method with the lowest incidence of postoperative complications.

Systematic Review Registration

PROSPERO, identifier: CRD42020221907.

Anal fistula plug vs rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis of studies with long-term follow-up

AIM

The aim was to compare the effectiveness of the anal fistula plug (AFP) with the rectal advancement flap (RAF) for complex cryptoglandular anal fistulas.

METHODS

We conducted a literature search to identify relevant available articles published without language restriction from Embase and PubMed databases and the Cochrane Library. Studies comparing outcomes with the AFP vs RAF for complex cryptoglandular anal fistulas were eligible for inclusion.

RESULTS

A total of 11 articles with 810 patients were included in this meta-analysis. Four RCTs and one observational clinical study provided long-term follow-up. The pooled analysis of all 11 studies indicated that there was no significant difference between the AFP and RAF in terms of healing rate, recurrence rate and incidence of fistula complications. However, the pooled results of studies with long-term follow-up revealed that the RAF group had a significantly higher healing rate (OR 0.32, 95% CI 0.13, 0.78, P = 0.01) and lower recurrence rate (OR 4.45, 95% CI 1.45, 13.65, P = 0.009) than the AFP group.

CONCLUSIONS

For the treatment of complex cryptoglandular anal fistulas, the RAF was superior to the AFP in terms of healing and recurrence rate after pooling of randomized controlled trials with long-term follow-up, even though a comparison based on the pooling of all studies showed no significant difference.

The treatment of anal fistula: second ACPGBI Position Statement - 2018

It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

BACKGROUND

Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement.

OBJECTIVE

The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence.

DESIGN AND SETTINGS

A retrospective review was performed at 3 university-affiliated teaching hospitals.

PATIENTS

All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded.

MAIN OUTCOME MEASURES

The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed.

RESULTS

Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics.

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSIONS

Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Predictive factors for recurrence of cryptoglandular fistulae characterized by preoperative three-dimensional endoanal ultrasound

AIM

Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS).

METHOD

Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula.

RESULTS

There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2-118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2-51), P = 0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0-4.6), P = 0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%.

CONCLUSION

The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.

Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review

AIM

Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.

METHOD

A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken.

RESULTS

We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study.

CONCLUSION

Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.

A New Surgical Device for Minimally Invasive “Core-Out” Excision of High Fistula-in-Ano

Core fistulectomy with endorectal advancement flap repair has been reported as a safe and effective technique for treatment of high fistula-in-ano. A number of rigid and flexible fistulectomy sets have already been fabricated pursuing the objectives of facilitating the procedure of this conservative surgical technique and reducing its risks of continence impairment. Two different methods (the method of scraping the granulation tissue of fistula and the method of separating and removing a thin layer from inside of tract) have been served in these sets for obliterating the abnormalities. In this work, with the aim of minimizing invasion to healthy tissue encircling the fistula, specially sphincter muscles, we designed and fabricated a new flexible fistulectomy device, which uses the second mentioned method. The new set separates an approximately 2.5-mm-thick layer from inside of the fistulous tract, by rotating a special tubular blade around its axis and moving the blade along the fistulous tract from external orifice toward the internal orifice. At the same time, the separated tissue may be removed from the fistulectomy lumen by rotating a special cannulated screw embedded coaxially inside the tubular blade. A flexible guidewire was used for identifying the tract path and guiding the device along it. We used the new set for excising 10 curved fistula models of approximately 16 cm length and 1.5 mm diameter, which were created in cubic pieces of fresh cow muscle as test specimens. After removing the device, each specimen was left with a smooth-walled lumen of approximately 9 mm diameter. The tubular blade works very well in separating a thin layer from inside of the fistula models and the cannulated screw is capable of easily removing the separated tissue. The removed tissue could be used as a sample of the whole tract for histopathological examinations. The screw and flexible guidewire lead the blade along the tract in a good manner and ensure circumferential separation of the fistula. With regard to the results of our tests, it is anticipated that the new set is an efficient instrument for easy, safe and fast core-out excision of high anal fistulas and is able to reduce the risk of injuries to healthy tissue encircling the fistulous tract.

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.

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.

The surgical management of fistula-in-ano in a specialist colorectal unit

INTRODUCTION

Fistula-in-ano can be associated with a number of conditions, including Crohn's disease. The majority, however, are classified as idiopathic or cryptoglandular. The aim of this study was to review the outcome of surgical management of fistula-in-ano in a specialist colorectal unit.

MATERIALS AND METHODS

One hundred and four consecutive patients underwent surgery for anal fistulae between 1st January 2000 and December 2004. Data was analysed in two main groups, according to the aetiology, cryptoglandular (n = 86) and Crohn's disease (n = 18). Follow-up data was available on 91 patients.

RESULTS

In the cryptoglandular group, 62 patients had an inter-sphincteric tract, of which 48 underwent a single-stage fistulotomy. Of those patients with a trans-sphincteric tract, six patients underwent a single-stage fistulotomy, 13 had a seton and staged fistulotomy. Follow-up data revealed that two fistulae recurred. The median number of procedures in this group was 1 (range 1-3). There was a significant difference in the inpatient stay depending of Park's classification (p = 0.001). In the Crohn's group, three patients with an inter-sphincteric tract underwent a single-stage fistulotomy, two patients with a trans-sphincteric tract had single-stage fistulotomy, and five required a loose seton and staged fistulotomy. Eight patients had multiple fistulae which required long-term setons. Four patients from this group eventually required proctectomy. In the Crohn's group, there was a significantly increased complexity of surgery and higher recurrence. This was reflected in an increased inpatient length of stay and a greater reliance on imaging (p = 0.001). The median number of procedures in this group was 3 (range 1-5).

DISCUSSION

The majority of cryptoglandular fistula-in-ano were treated by primary fistulotomy or staged fistulotomy with a loose seton. This was associated with a low recurrence rate and low rates of faecal incontinence. There was a low reliance on imaging techniques in this group. However, we would urge caution when dealing with fistula-in-ano related to Crohn's disease. In this group of patients, the fistulae tended to be more complex and require additional imaging and multiple procedures.

Fibrin glue and transanal rectal advancement flap for high transsphincteric perianal fistulas; is there any advantage?

BACKGROUNDS AND AIM

In recent decades, fibrin glue has appeared as an alternative treatment for high perianal fistulas. Early results seemed promising, with high success rates being reported. However, with increasing follow-up, the enthusiasm was tempered because of disappointing results. The aim of this retrospective study was to assess the additional value of fibrin glue in combination with transanal advancement flap, compared to advancement flap alone, for the treatment of high transsphincteric fistulas of cryptoglandular origin.

MATERIALS AND METHODS

Between January 1995 and January 2006, 127 patients were operated for high perianal fistulas with an advancement flap. After exclusion of patients with inflammatory bowel disease or HIV, 80 patients remained. A consecutive series of 26 patients had an advancement flap combined with obliteration of the fistula tract with fibrin glue. Patients were matched for prior fistula surgery, and the advancement was performed identically in all patients. In the fibrin glue group, glue was installed retrogradely in the fistula tract after the advancement was completed and the fistula tract had been curetted.

RESULTS

Minimal follow-up after surgery was 13 months [median of 67 months (range, 13-127)]. The overall recurrence rate was 26% (n=21). Recurrence rates for advancement flap alone vs the combination with glue were 13% vs 56% (p=0.014) in the group without previous fistula surgery and 23% vs 41% (p=0.216) in the group with previous fistula surgery.

CONCLUSION

Obliterating the fistula tract with fibrin glue was associated with worse outcome after rectal advancement flap for high perianal fistulas.

Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula

BACKGROUND

Endoanal advancement flap repair is widely used in sphincter-preserving surgery for anal fistula, but the high recurrence rate is a major problem. A possible cause of non-healing is local infection of the flap. The aim of this study was to evaluate whether local antibiotic treatment with gentamicin-collagen improves healing after endoanal advancement flap repair for anal fistula.

METHODS

Eighty-three patients (52 men and 31 women; mean age 47 (range 17-71) years) who had endoanal advancement flap repair for anal fistula between September 1998 and January 2004 were randomized to surgery with (42 patients) or without (41 patients) application of gentamicin-collagen beneath the flap. Patients were evaluated at 1-3 and 12 months after surgery for healing and/or recurrence.

RESULTS

The overall healing rate with no recurrence at 1 year after surgery was 57 per cent (47 of 83). Twenty-six of 42 patients randomized to gentamicin-collagen healed primarily compared with 21 of 41 patients randomized to surgery only. There were no overall differences in healing rate according to sex, previous fistula surgery, complexity of fistula, smoking habit or body mass index.

CONCLUSION

Endoanal advancement flap repair for anal fistula has a fairly high primary recurrence rate. Healing was not significantly improved by local application of gentamicin-collagen.

New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant

There have been several recent advances in the treatment of common perianal diseases. Stapled hemorrhoidopexy is a procedure of hemorrhoidal fixation, combining the benefits of rubber band ligation into an operative technique. The treatment of anal fissure has typically relied upon internal sphincterotomy; however, it carries a risk of incontinence. The injection of botulinum toxin represents a new form of sphincter relaxation, without division of any sphincter muscle; morbidity is minimal and results are promising. For the treatment of fistula in a fistulotomy remains the gold standard, however, it carries significant risk of incontinence. Use of fibrin sealant to treat fistulae has been met with variable success. It offers sealing of the tract, and then provides scaffolding for native tissue ingrowth.

Fístula anal de origen criptoglandular. Opciones terapéuticas

Anal fistula is a frequent condition. The most commonly accepted origin is infectious. The most widely used classification is based on cryptoglandular theory and on the position of the fistulous tract in relation to the anal sphincter. Physical examination will help to identify the type of fistula and allow its treatment to be planned. The most widely used complementary tests are endoanal ultrasound and magnetic resonance imaging. We review the various therapeutic options and their results, especially fistulotomy, endorectal advancement flap, use of sedal, anodermal advancement flap, sphincterorrhaphy with sphincter repair, and fibrin glue.

Treatment of fistulas-in-ano with fibrin sealant in combination with intra-adhesive antibiotics and/or surgical closure of the internal fistula opening

PURPOSE

The treatment of fistulas-in-ano with fibrin sealant injection has been moderately successful. Failures can be caused by persistent infection within the tract or early expulsion of the clot. In an attempt to improve the success rate, we examined three modifications of the sealant procedure: the addition of cefoxitin to the sealant, surgical closure of the primary opening, or both.

METHODS

A prospective, randomized, clinical trial was performed in which patients were treated with Tisseel-VH fibrin sealant according to previously published procedures. In addition, patients were randomized to receive intra-adhesive cefoxitin, surgical closure of the primary opening, or both modifications. Cefoxitin, 100 mg, was added to the sealant for patients randomized to receive intra-adhesive antibiotics. For the appropriate patients, the primary fistula opening was closed with a 3-0 absorbable suture. If fistulas failed to heal, patients were offered a single retreatment with sealant.

RESULTS

Twenty-four patients were treated in the cefoxitin arm, 25 in the closure arm, and 26 in the combined arm. Median duration of fistulas was 12 months. Patients were followed for a mean of 27 months postoperatively. There was no postoperative incontinence or complications related to the sealant itself. Initial healing rates were 21 percent in the cefoxitin arm, 40 percent in the closure arm, and 31 percent in the combined arm (P = 0.35). One of five patients in the cefoxitin arm, one of seven patients in the closure arm, and one of six patients in the combined arm were successfully retreated; final healing rates were 25, 44, and 35 percent respectively (P = 0.38).

CONCLUSIONS

Treatment of fistula-in-ano with fibrin sealant with closure of the internal opening was somewhat more successful than sealant with cefoxitin or the combination, however this did not achieve statistical significance. None of the three modifications were more successful than historic controls at our institution treated with sealant alone. Therefore, the addition of intra-adhesive cefoxitin, closure of the internal opening, or both are not recommended modifications of the fibrin sealant procedure.

Ano-cutaneous flap repair for complex and recurrent supra-sphincteric anal fistula

BACKGROUND

Suprasphincteric fistulae remain the most difficult to cure.

OBJECTIVES

The purpose of this study was to evaluate the healing rate of suprasphincteric anal fistula treated by ano-cutaneous advancement flap repair, and the impact of this procedure on continence and quality of life.

METHOD

Sixteen patients with complex, recurrent or chronic suprasphincteric fistulae associated with significant tissue damage (necrotizing fasciitis, keyhole deformity and anal stenosis) or who had failed previous surgical procedures were treated by ano-cutaneous flap closure. They were assessed pre and postoperatively by the treating surgeon for wound healing and fistula recurrence and later followed up by phone interview using the St Mark's Hospital incontinence score and the Perianal Disease Activity Index (PDAI) as indicators of treatment outcome.

RESULTS

Fifteen patients had successful healing of their fistula with the cutaneous flap, with recurrence in only one. The most common short-term complications were minor graft site wound separation, which healed in all cases without intervention, and wound pain, which settled over time and was not associated with recurrence. Continence improved for almost 70% of the patients, with a significant reduction in St Mark's incontinence scores (t = 2.62, 15 d.f., P = 0.02). PDAI also decreased significantly (t = 7.55, 15 d.f., P < 0.001), demonstrating improvement in quality of life for most patients.

CONCLUSION

Ano-cutaneous flap can achieve healing of complex and recurrent suprasphincteric anal fistula in patients who had previously failed at other forms of treatment thus improving their quality of life and continence.

Anocutaneous V-Y advancement flap for the treatment of complex perianal fistula

PURPOSE

The treatment of intersphincteric and low transsphincteric fistula is well defined, but controversy remains around the management of complex perianal fistula. This study was designed to assess the utility of anocutaneous flap repair in complex types of perianal fistula.

METHODS

Sixty-five perianal fistula in 65 patients treated with anocutaneous advancement flap for the complex fistula, between April 1998 and December 2002, are included this prospective study. Mean age was 34 +/- 2.1 (range, 24-53) years. Magnetic resonance imaging was used for the diagnosis of fistula. Excision of the internal opening and the overlying anoderm, curettage of the fistula tract, closure of internal opening with absorbable polyglactin 3/0 suture, and drainage of the external opening(s) by insertion of penrose drain were common operational steps. Outcome was evaluated in terms of healing and incontinence.

RESULTS

Successful healing of 59 of 65 complex fistulas was achieved using this technique with no disturbance of continence and minimal complications. Mean follow-up and complete healing time were 32 +/- 0.6 (range, 12-52) months and 5.4 +/- 0.8 (range, 3-7) weeks respectively.

CONCLUSIONS

Although the study cases were relatively small in number, this report showed that clinical results of anocutaneous advancement flap are acceptable. However, large studies are needed to reach an ultimate conclusion for assessing the place of anocutaneous flap advancement in complex fistula.

Direct appositional (no flap) closure of deep anal fistula

OBJECTIVE

After sphincter-sparing core fistulectomy for deep anal fistula most surgeons advance a rectal mucosal flap to reinforce closure of the internal opening. Our own method having for many years been simple appositional closure the resulting series presented an opportunity for comparison.

PATIENTS AND METHODS

From November 1987 to January 2001, 44 patients underwent 46 core fistulectomies with flap-less direct appositional closure in our unit. Records were kept prospectively. Twenty-six fistulae (in 28 patients) appeared healed at two to five months follow-up and the patients had been discharged. A full review was mounted in May 2001, when 16 of the healed patients could be contacted and questionnaires completed. Two patients were excluded from the study.

RESULTS

The procedure failed in 16 patients initially and was found to have done so in two more at long-term follow-up (41% overall). Three patients had died and five could not be traced.

CONCLUSION

Simple appositional closure after core fistulectomy for deep anal fistula seems inferior to methods using flap reinforcement.

Anocutaneous advancement flap repair of transsphincteric fistulas

PURPOSE

The purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after anocutaneous advancement flap repair and to examine the impact of this procedure on fecal continence.

METHODS

Between January 1997 and June 1999, 26 consecutive patients with a transsphincteric perianal fistula passing through the middle or upper third of the external anal sphincter underwent anocutaneous advancement flap repair. There were six female patients, and the median age was 39 (range, 27-54) years. Twenty patients (77 percent) had previously undergone one or more prior attempts at repair. With the patient in the prone-jackknife position, the internal opening of the fistula was exposed using a Lone Star Retractor System, and the crypt-bearing tissue around the internal opening as well as the overlying anoderm was excised. An (inverted) U-shaped flap, including perianal skin and fat, was created. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the mucosa and underlying internal anal sphincter proximal to the closed internal opening. The median follow-up time was 25 months. Fecal continence was evaluated in 23 patients by means of a questionnaire.

RESULTS

Anocutaneous advancement flap repair was successful in 12 patients (46 percent). Success was inversely correlated with the number of prior attempts. In patients who had undergone no or only one previous attempt at repair (n = 9), the healing rate was 78 percent. In patients with two or more previous repairs (n = 17) the healing rate was only 29 percent. In seven patients (30 percent) continence deteriorated after anocutaneous advancement flap repair. Eleven patients (48 percent) had a completely normal continence preoperatively. Two of these patients (18 percent) encountered soiling and incontinence for gas after the procedure, whereas two subjects (18 percent) complained of accidental bowel movements. Twelve patients (52 percent) presented with continence disturbances at the time of admission to our hospital. In this group, deterioration was observed in two patients (17 percent).

CONCLUSION

The results of anocutaneous advancement flap repair in patients with no or only one previous attempt at repair are moderate. In patients who have undergone two or more previous attempts at repair the outcome is poor. Based on the relatively low healing rate and deterioration of continence, this procedure seems less suitable for high transsphincteric fistulas than transanal mucosal advancement flap repair.