Is the Outcome of Transanal Advancement Flap Repair Affected by the Complexity of High Transsphincteric Fistulas?

• Published in: Diseases of the colon & rectum Vol. 54; no. 7; pp. 857 - 862
• Main Authors: Mitalas, Litza E, Dwarkasing, Roy S, Verhaaren, Rob, Zimmerman, David D. E, Schouten, W. Rudolph
• Format: Journal Article
• Language: English
• Published: Hagerstown, MDc The ASCRS 01.07.2011; Lippincott Williams & Wilkins
• Subjects: Adult; Aged; Anal Canal - surgery; Biological and medical sciences; Female; Follow-Up Studies; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Magnetic Resonance Imaging; Medical sciences; Middle Aged; Rectal Fistula - diagnosis; Rectal Fistula - surgery; Retrospective Studies; Skin plastic surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgical Flaps; Suture Techniques; Treatment Outcome; Wound Healing; Young Adult; Prognosis; Abscess; Transanal advancement flap repair; Fistula; Nuclear magnetic resonance imaging; Perianal fistula; Extension; Treatment; Perianal; Surgery; Associated abscesses; Endoanal magnetic resonance imaging; Horseshoe extension; Gastroenterology; Medical imagery; Advancement flap
• ISSN: 0012-3706; 1530-0358
• DOI: 10.1007/DCR.0b013e31820eee2e

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 extensionsa 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 extensionsa 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.