TRANSANAL RECTAL ADVANCEMENT FLAP VS MUCO SAL FLAP WITH SUTURE OF THEINTERNAL SPHINCTER MUSCLE FOR THE MANAGEMENT OF COMPLICATED ANORECTALFISTULAS - A PROSPECTIVE CLINICAL AND MANOMETRIC STUDY

A prospective study was carried out on 55 patients with complicated an al fistulas (41 transsphincteric, 5 suprasphincteric and 9 rectovagina l) to evaluate the value of two sphincter-conserving techniques with p rimary occlusion of the internal ostium and endorectal advancement fla p (group A, n=34) or mucosal flap (group B, n=21). Ten of the patients had Crohn's disease. Both techniques consist in one-stage fistulectom y without drainage of the intersphincteric space. The inflamed proctod eal and granulation tissue was carefully cleared. The site of the form er primary orifice of the fistula was adapted by means of two or three peranally performed single stitches. The peranally applied suture inc luded the layers of the internal anal sphincter muscle only. A mobiliz ed flap of rectal wall (group A) and rectal mucosa and submucosa (grou p B) about 4 cm x 3 cm in size was stitched below the muscular sphinct er. The perianal part of the wound was left to heal by second intentio n. Postoperatively there were 16 cases of suture leakage (23.5% in gro up A, and 38% in group B), and 19 patients (26% or 47% in both groups) had to have revision surgery because of recurrent fistula or sutur le akage; 2 patients (3.6%) developed incontinence with intermittent feca l soiling. Complete incontinence was not observed in any patient. No s ignificant difference in clinical and functional results was determine d between the two groups.