Repeat transanal advancement flap repair: impact on the overall healing rate of high transsphincteric fistulas and on fecal continence.
OBJECTIVE
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.
Mitalas
Litza E
LE
Colorectal Research Group Rotterdam, Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
Gosselink
Martijn P
MP
Zimmerman
David D E
DD
Schouten
W Ruud
WR
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D013505:Digestive System Surgical Procedures / Q000009:adverse effects*; D005242:Fecal Incontinence / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012003:Rectal Fistula / Q000473:pathology* / Q000601:surgery*; D012086:Reoperation / Q000009:adverse effects; D013524:Surgical Flaps / Q000009:adverse effects*; D016896:Treatment Outcome; D014945:Wound Healing
Dis Colon Rectum. 1999 Nov;42(11):1419-22; discussion 1422-3
10566529
Dis Colon Rectum. 1999 Dec;42(12):1525-32
10613469
Br J Surg. 2000 Dec;87(12):1680-3
11122184
Dis Colon Rectum. 2002 Mar;45(3):349-53
12068193
Dis Colon Rectum. 2002 Dec;45(12):1608-15
12473883
Dis Colon Rectum. 2002 Dec;45(12):1616-21
12473884
Dis Colon Rectum. 2002 Dec;45(12):1622-8
12473885
Br J Surg. 2003 Mar;90(3):351-4
12594672
Dis Colon Rectum. 2003 Dec;46(12):1674-9
14668594
Dis Colon Rectum. 2004 Jul;47(7):1174-80
15148648
Surgery. 1983 Feb;93(2):330-2
6823674
Dis Colon Rectum. 1985 Jul;28(7):496-8
4017809
Br J Surg. 1987 May;74(5):390-1
3594132
Dis Colon Rectum. 1987 Dec;30(12):919-23
3691261
Surgery. 1993 Oct;114(4):682-9; discussion 689-90
8211682
Dis Colon Rectum. 1996 Jan;39(1):10-4
8601343
Am Surg. 2004 Oct;70(10):925-7
15529853
J Gastrointest Surg. 1997 Sep-Oct;1(5):487-91
17061335