title: Complex anal fistulas: plug or flap?
abstract: BACKGROUND
  Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair.
  
  
  METHODS
  A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging.
  
  
  RESULTS
  Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty-one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch-vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty-eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty-two FPs (31% of total) were performed with 7 successful repairs (32%, P = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P = 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%.
  
  
  CONCLUSIONS
  The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.
authors.affiliation: Colorectal Unit, Department of Surgery, Auckland City Hospital, Auckland, New Zealand. markmuhlmann@sydneycolorectal.com.au
authors.forename: Mark D
authors.initials: MD
authors.lastname: Muhlmann
authors.forename: Julian L
authors.initials: JL
authors.lastname: Hayes
authors.forename: Arend E H
authors.initials: AE
authors.lastname: Merrie
authors.forename: Bryan R
authors.initials: BR
authors.lastname: Parry
authors.forename: Ian P
authors.initials: IP
authors.lastname: Bissett
mesh_terms: D000328:Adult; D001705:Bioprosthesis; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007413:Intestinal Mucosa / Q000637:transplantation*; D007902:Length of Stay; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D012003:Rectal Fistula / Q000175:diagnosis / Q000601:surgery*; D012189:Retrospective Studies; D013524:Surgical Flaps; D013630:Tampons, Surgical; D016896:Treatment Outcome; D014945:Wound Healing