LONG-TERM ANALYSIS OF THE USE OF TRANSANAL RECTAL ADVANCEMENT FLAPS FOR COMPLICATED ANORECTAL VAGINAL FISTULAS

Transanal rectal advancement flap (TRAF) is a surgical option in the m anagement of rectovaginal and other complicated fistulas involving the anorectum. Most reported series have a short follow-up. PURPOSE: This study was undertaken to determine the long-term success, safety, appl icability, and factors affecting recurrence in patients managed with T RAF, including patients with Crohn's disease. METHODS/MATERIALS: Retro spective analysis of all patients undergoing endorectal advancement fl aps at a single institution between 1988 and 1993 was performed. One h undred one patients were identified (70 percent female; 30 percent mal e). Included were 52 patients with rectovaginal, 46 with anal perineal , and 3 with rectourethral fistulas. Causes were obstetric injury in 1 3 patients, Crohn's disease in 47, cryptoglandular in 19, mucosal ulce rative colitis in 7, and surgical trauma or undefined causes in 15 pat ients. RESULTS: No mortality occurred. Median follow-up was 31 (range, 1-79 months). Immediate failure (within one week of the repair) was s een in 6 percent of patients. Statistically (P < 0.001) higher recurre nce rates were observed in patients who had undergone previous repairs . Mean hospital stay was four days. Overall recurrence was seen in 29 patients (29 percent). Seventy-five percent of all recurrences occurre d within the first 15 months; however, recurrence was noted for up to 55 months after repair. Etiology of fistula, use of constipating medic ations, antibiotic use, and most importantly associated Crohn's diseas e did not statistically affect recurrence rates. Failure rate was only influenced by previous number of repairs. CONCLUSION: TRAF is a safe technique for managing complicated anorectal and rectovaginal fistulas , including patients with Crohn's disease. Long-term follow-up is esse ntial to accurately report recurrence rates.