Repeat Transanal Advancement Flap Repair: Impact on the Overall Healing Rate of High Transsphincteric Fistulas and on Fecal Continence

Abstract

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.

Practice Parameters for the Management of Perianal Abscess and Fistula-in-Ano

“…In general, recurrence rates range from 13% to 56%. [81][82][83] The addition of fibrin glue to obliterate the tract has failed to improve success rates. 81,84 Factors associated with failed repair include radiation, underlying Crohn's disease, active proctitis, rectovaginal fistula, malignancy, and number of prior attempted repairs.…”

Revisiting an ancient treatment for transphincteric fistula-in-ano ‘There is nothing new under the sun’ Ecclesiastes 1v9

“…Published results vary with respect to success of treatment, recurrence, technique used, patient cohort and length of follow-up. 6,[12][13][14][15][17][18][19] Prognosis is also affected by the complexity of the fistula and any secondary underlying disease that can affect fistula healing. However, treatment is considered successful and complete when the patient is free from fistula, has maintained continence and the fistula does not recur.…”

Endorectal Advancement Flap

“…Encouraging fi ndings regarding continence have been found by a number of studies, which have found no change in continence after fl ap [ 46 , 47 ] or only transient changes in continence [ 15 ]. Similarly, when the Rockwood Fecal Incontinence Severity Index was measured preoperatively and postoperatively after initial and even repeat fl aps, no change in scores was found [ 18 ]. Some studies even report improved continence after fl ap, perhaps because there is no longer drainage through the fi stula tract [ 5 , 35 ].…”

“…Mitalas et al performed a second advancement fl ap in 26 patients with transsphincteric cryptoglandular fi stulas who had recurrence after an initial rectal advancement fl ap [ 18 ]. The healing rate after the second fl ap was 69 %.…”