Novel surgical procedure in design of advancement endorectal flap in the surgical treatment of complex anal fistulas
Authors:
J. Korček; A. Lazorišák; T. Jankovič
Published in:
Rozhl. Chir., 2023, roč. 102, č. 10, s. 387-394.
Category:
Original articles
doi:
https://doi.org/10.33699/PIS.2023.102.10.387–394
Overview
Introduction: Anal fistula is a common disease with incidence of 5.6 per 100,000 women and 12.3 men. It is most often of cryptoglandular origin. The aim of this study is to evaluate our experience with patients treated for complex anal fistula with our own complex surgical procedure with advancement endorectal flap.
Methods: 524 patients with complex anal fistulas who were sent to our surgical clinic from January 2005 to the end of December 2022 were in- cluded in the study. We established the diagnosis by detecting the fistula tract by physical examination, anoscopy, probing the fistula tract and endorectal ultrasonography. We performed a complex operation together with the construction of the advancement endorectal flap in our own modification for all patients.
Results: Primary surgical intervention in a group of 326 patients with complex anal fistulas (excluding patients with Crohn‘s disease) was successful in 283 (87%) patients. We identified advancement endorectal flap defect in the postoperative period in 17 (5.2%) patients, soiling in 16 (4.9%) and flatus incontinence in 9 (2.7%) patients. In a group of 120 patients after multiple surgeries (excluding patients with Crohn‘s disease), our surgical procedure was successful in 92 (76.6%) patients. In the postoperative period, we identified a advancement endorectal flap defect in 6 (5%) patients, soiling in 8 (6.6%) and flatus incontinence in 3 (2.5%) patients.
Conclusions: The construction of the advacement endorectal flap was curative and without affecting the level of anal continence in 87% of patients after primary surgical intervention and in 76.6% after multiple surgical procedures. Complex surgery with the construction of the advancement endorectal flap according to our procedure preserves the function of the sphincters and has a relatively low percentage of recurrences. The number of previous surgical interventions had no affect on the level of anal continence.
Keywords:
advacement endorectal flap – complex fistula-in-ano – recovery of mm. sphincteris ani externi
Sources
1. Willis S, Rau M, Schumpelick V. Surgical treatment of high anorectal and rectovaginal fistulas with the use of transanal endorectal advancement flaps. [Article in German], Chirurg 2000;71:836−840. doi: 10.1007/s 001040051145.
2. Zimmerman DE, Stijns J, Daria K, et al. Transanal advancement flap repair: The current gold standard for cryptoglandular transsphincteric perianal fistulas. Turk J Colorectal Dis. 2019;29:104−110. doi: 10.4274/tjcd.galenos.2019.06-2.
3. Balciscueta Z, Uribe N, Balciscueta I, et al. Rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis. Int J Colorectal Dis. 2017;32:599−609. doi: 10.1007/s00384-017-2779-7.
4. Schouten WR, Zimmerman DD, Briel JW. Transanal advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 1999;42:1419−1422. doi: 10.1007/ BF02235039
5. Pinedo GM, Caselli MG, Urrejola SG, et al. Modified loose-seton technique for the treatment of complex anal fistulas. Colorectal Dis. 2010;12(10 On-line): e310–e313. doi: 10.1111/j.1463-1318.2010.02195.x
6. Ellis CN, Clark S. Fibrin glue as an adjunct to flap repair of anal fistulas: a randomized, controlled study. Dis Colon Rectum 2006;49:1736−1740. doi: 10.1007/ s10350-006-0718-8.
7. Cintron JR, Park JJ, Orsay CP, et al. Abcarian H. Repair of fistulas-in-ano using autologous fibrin tissue adhesive. Dis Colon Rectum 1999;42:607−613. doi: 10.1007/ BF02234135.
8. van Koperen PJ, Bemelman WA, Bossuyt PM, et al. The anal fistula plug versus the mucosal advancement flap for the treatment of anorectal fistula (PLUG trial). BMC Surg 2008;8:11. doi: 10.1186/14712482-8-11.
9. Williams JG, MacLeod CA, Rothenberger DA, et al. Seton treatment of high anal fistulae. Br J Surg. 1991;78:1159–1161. doi: 10.1002/bjs.1800781004.
10. Mitalas LE, van Wijk JJ, Gosselink MP, et al. Seton drainage prior to transanal advancement flap repair: useful or not? Int J Colorectal Dis. 2010;25:1499–1502. doi: 10.1007/s00384-010-0993-7.
11. Eitan A, Koliada M, Bickel A. The use of the loose seton technique as a definitive treatment for recurrent and persistent high trans-sphincteric anal fistulas: a long-term outcome. J Gastrointest Surg. 2009 Jun;13(6):1116−1119. doi: 10.1007/s11605-009-0826-6.
12. Galis-Rozen E, Tulchinsky H, Rosen A, et al. Long-term outcome of loose seton for complex anal fistula: a two-centre study of patients with and without Crohn‘s disease. Colorectal Dis. 2010 Apr;12(4):358−362. doi: 10.1111/j.14631318.2009.01796.x. Epub 2009 Feb 7.
13. Subhas G, Gupta A, Balaraman S, et al. Non-cutting setons for progressive migration of complex fistula tracts: a new spin on an old technique. Int J Colorectal Dis. 2011 Jun;26(6):793−798. doi: 10.1007/s00384-011-1189-5.
14. Sirikurnpiboon S, Awapittaya B, Jivapaisarnpong P. Ligation of intersphincteric fistula tract and its modification: Results from treatment of complex fistula. World J Gastrointest Surg. 2013;5:123–128. doi: 10.4240/wjgs.v5.i4.123.
15. Mushaya C, Bartlett L, Schulze B, et al. Ligation of intersphincteric fistula tract compared with advancement flap for complex anorectal fistulas requiring initial seton drainage. Am J Surg. 2012 Sep;204(3):283−289. doi: 10.1016/j.amjsurg.2011.10.025.
16. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–196. Ann Surg. 2009 Aug;250(2):187−196. doi: 10.1097/ SLA.0b013e3181b13ca2.
17. Perez F, Arroyo A, Serrano P, et al. Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano. Am J Surg. 2006 Jul;192(1):34-40. doi: 10.1016/j.amjsurg.2006.01.028.
18. Ortiz H, Marzo M, de Miguel M, et al. Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano. Br J Surg. 2008 Apr;95(4):484−487. doi: 10.1002/bjs.602
19. Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn’s fistula-in-ano. Dis Colon Rectum 2010 Apr;53(4):486–495. doi: 10.1007/ DCR.0b013e3181ce8b01.
20. Mitalas LE, Gosselink MP, Zimmerman DD, et al. Repeat transanal advancement flap repair: impact on the overall healing rate of high transsphincteric fistulas and on fecal continence. Dis Colon Rectum 2007 Oct; 50(10): 1508–1511. doi: 10.1007/s10350-007-9015-4
21. Aguilar PS, Plasencia G, Hardy TG Jr, et al. Mucosal advancement in the treatment of anal fistula. Dis Colon Rectum 1985 Jul;28(7):496-8. doi: 10.1007/ BF02554093.
22. Elting AW. X. The treatment of fistula in ano: With especial reference to the whitehead operation. Ann Surg. 1912 Nov;56(5):744−752. doi: 10.1097/ 00000658-191211000-00010.
23. Hamalainen KP, Sainio AP. Cutting seton for anal fistulas: high risk of minor control defects. Dis Colon Rectum 1997 Dec;40(12):1443−1446; discussion 1447. doi: 10.1007/BF02070710.
24. Ozuner G, Hull TL, Cartmill J, et al. Longterm analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum 1996 Jan;39(1):10−14. doi: 10.1007/ BF02048261.
25. Tan KK, Alsuwaigh R, Tan AM, et al. To LIFT or to flap? Which surgery to perform following seton insertion for high anal fistula? Dis Colon Rectum 2012 Dec;55(12):1273-1277. doi: 10.1097/ DCR.0b013e31826dbff0.
26. Yellinek S, Krizzuk D, Moreno Djadou T, et al. Endorectal advancement flap for complex anal fistula: does flap configuration matter? Colorectal Dis. 2019 May;21(5):581−587. doi: 10.1111/ codi.14564.
27. Dubsky PC, Stift A, Friedl J, et al. Endorectal advancement flaps in the treatment of high anal fistula of cryptoglandular origin: full-thickness vs. mucosal-rectum flaps. Dis Colon Rectum 2008 Jun;51(6):852−857. doi: 10.1007/s10350008-9242-3.
28. Khafagy W, Omar W, El Nakeeb A, et al. Treatment of anal fistulas by partial rectal wall advancement flap or mucosal advancement flap: a prospective randomized study. Randomized Controlled Trial Int J Surg. 2010;8(4):321−325. doi: 10.1016/j.ijsu.2010.03.009.
29. Jarrar A, Church J. Advancement flap repair: a good option for complex anorectal fistulas. Dis Colon Rectum 2011 Dec;54(12):1537−15341. doi: 10.1097/ DCR.0b013e31822d7ddd.
30. Seyfried S, Bussen D, Joos A. et al. Fistulectomy with primary sphincter reconstruction. Int J Colorectal Dis. 2018 Jul;33(7):911−918. doi: 10.1007/s00384018-3042-6.
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Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2023 Issue 10
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