Endorectal Advancement Flap for Cryptoglandular or Crohnʼs Fistula-in-Ano

• Published in: Diseases of the colon & rectum Vol. 53; no. 4; pp. 486 - 495
• Main Authors: Soltani, Ali, Kaiser, Andreas M.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MDc The ASCRS 01.04.2010; Lippincott Williams & Wilkins
• Subjects: Biological and medical sciences; Colorectal Surgery - methods; Crohn Disease - surgery; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Medical sciences; Other diseases. Semiology; Rectal Fistula - surgery; Rectum - surgery; Skin plastic surgery; Stomach. Duodenum. Small intestine. Colon. Rectum. Anus; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgical Flaps; Fistula in ano; Fistula; Review; Inflammatory disease; Crohn disease; Treatment; Perianal; Surgery; Gastroenterology; Systematic reviews; Digestive diseases; Intestinal disease; Perianal Crohn disease; Anorectal disease; Advancement flap; Bibliographic review
• ISSN: 0012-3706; 1530-0358; 1530-0358
• DOI: 10.1007/DCR.0b013e3181ce8b01

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 pointssuccess 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.