IntroductionTransanal 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.MethodsBetween 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.ResultsMedian 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.ConclusionPreoperative seton drainage does not improve the outcome of TAFR.

PURPOSE: Transanal advancement flap repair (TAFR) has been advocated as the treatment of choice for transsphincteric fistulas passing through the upper or middle third of the external anal sphincter. It is not clear whether previous attempts at repair adversely affect the outcome of TAFR. The purpose of the present study was to evaluate the success rate of a repeat TAFR and to assess the impact of such a second procedure on the overall healing rate of high transsphincteric fistulas and on fecal continence. METHODS: Between January 2001 and January 2005, a consecutive series of 87 patients (62 males; median age, 49 (range, 27-73) years) underwent TAFR. Median follow-up was 15 (range, 2-50) months. Patients in whom the initial operation failed were offered two further treatment options: a second flap repair or a long-term indwelling seton drainage. Twenty-six patients (male:female ratio, 5:2; median age, 51 (range, 31-72) years) preferred a repeat repair. Continence status was evaluated before and after the procedures by using the Rockwood Faecal Incontinence Severity Index (RFISI). RESULTS: The healing rate after the first TAFR was 67 percent. Of the 29 patients in whom the initial procedure failed, 26 underwent a repeat TAFR. The healing rate after this second procedure was 69 percent, resulting in an overall success rate of 90 percent.Both before and after the first attempt of TAFR, the median RFISI was 7 (range, 0-34). In patients who underwent a second TAFR, the median RFISI before and after this procedure was 9 (range, 0-34) and 8 (range, 0-34), respectively. None of these changes were statistically significant. CONCLUSIONS: Repeat TAFR increases the overall healing rate of high transsphincteric fistulas from 67 percent after one attempt to 90 percent after two attempts without a deteriorating effect on fecal continence.

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BackgroundAt 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).MethodsForty-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.ResultsEpithelialization 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.ConclusionsEpithelialization of high transsphincteric fistulas is rare and does not affect the outcome of TAFR and TAFR combined with LIFT.

Transanal advancement flap repair has been advocated as the treatment of choice for trans-sphincteric perianal fistulas, because it enables the healing of almost all fistulas without sphincter damage and consequent continence disturbance. After initial promising reports, recently less favorable results have been reported. It remains unclear why there is such a large variety in the reported healing rates. Recently, it has been suggested that impaired wound healing caused by a diminished rectal mucosal perfusion in patients who smoke may lead to the breakdown of the advancement flap in patients undergoing flap repair for perianal fistulas. This study was designed to investigate the difference in blood flow in rectal mucosa between patients who smoke and those who do not smoke. Furthermore, we assessed the impact of the creation of a mucosa advancement flap and the difference in blood flow in the flap between smoking and nonsmoking patients. Between July 2001 and July 2002, 23 consecutive patients (19 males; median age, 46 (range, 26-69) years) with a perianal fistula of cryptoglandular origin underwent surgery for a perianal fistula. Among them were 13 patients who smoked cigarettes. All patients underwent intraoperative laser Doppler flowmetry. Median blood flow before transanal advancement flap repair was 35 (range, 8-70) volts in patients who did not smoke. In patients who smoked the median blood flow before transanal advancement flap repair was 18 (range, 7-35) volts. Blood flow was significantly lower in patients who smoked (P = 0.018; Mann-Whitney). In conclusion, it seems likely that impaired wound healing caused by a diminished rectal mucosal perfusion is a contributing factor in the breakdown of advancement flaps in patients who smoke cigarettes.