Clinical course after transanal advancement flap repair of perianal fistula in patients with Crohn's disease

Abstract

A total of 36 rectal advancement flap repairs were performed in 32 patients with perianal Crohn's disease. There were 12 anovaginal and 20 trans-sphincteric fistulas. Patients were followed prospectively for a mean of 19.5 months to evaluate postoperative recurrence rate. The prognostic influence of fistula type, rectal disease, intestinal disease and faecal diversion on recurrence was assessed. Four of 36 repairs showed primary failure, the operated fistula recurred in 11 patients after a median of 7 months, and a new fistula developed in six patients. The fistula recurrence rate was higher in patients with anovaginal fistula or Crohn's colitis but did not correlate with disease activity. Transitory mild incontinence of stool was observed in one patient only. Although rectal advancement flap repair does not cure perianal fistulas in most patients with Crohn's disease, those without Crohn's colitis may have long-term benefit. Short-term improvement of symptoms justifies this simple procedure even in patients with anovaginal fistula.

Contemporary surgical management of rectovaginal fistula in Crohn's disease

“…Seventeen out of twenty-four (71%) patients achieved primary healing after initial flap repair and a total of 22/24 patients had healing after further repairs. Similarly, Makowiec et al [25] and Crim et al [26] reported successful healing of RVF secondary to CD in 5/12 and 10/14 patients, respectively with this technique.Ruffolo et al [27] stress that the advantages of a flap procedures are a low chance of: producing a keyhole deformity, worsening fecal incontinence, or aggravation of patient's symptoms in case of failure. Additionally, there is no perineal wound and the presence of a stoma is not mandatory.…”

“…Seventeen out of twenty-four (71%) patients achieved primary healing after initial flap repair and a total of 22/24 patients had healing after further repairs. Similarly, Makowiec et al [25] and Crim et al [26] reported successful healing of RVF secondary to CD in 5/12 and 10/14 patients, respectively with this technique.…”

“…Most studies have only reported shortterm outcomes. Makowiec et al [25] evaluated perianal Crohn's fistulae in 32 patients who underwent RAF (12 patients had a RVF). Mean follow-up was 19.5 mo.…”

Systematic review of surgical interventions for Crohn's anal fistula

“…A summary of study characteristics is shown in Table  1, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75.…”

“…Eight retrospective30 37, 39 40, 42, 43, 44 46 and two prospective observational38 41 studies reported the outcome of mucosal advancement flaps in both Crohn's and cryptoglandular perianal fistulous disease. Of the 590 reported procedures, 204 were performed for Crohn's fistula.…”