ENDORECTAL ADVANCEMENT FLAP VS TRANSPERIN EAL REPAIR IN THE TREATMENTOF RECTOVAGINAL FISTULAS - A LONG-TERM PROSPECTIVE-STUDY ON 88 PATIENTS

A prospective study was carried out on 88 patients with rectovaginal f istulae to evaluate the value of two sphincter-saving techniques: prim ary occlusion of the intraanal ostium and endorectal advancement flap (n = 37) or transperineal repair with levator interposition (n = 34). Causes were Crohn's disease 35, obstetric injury 31, proctological-gyn ecological operation 11, cryptoglandular 11. Perineal group: 11 patien ts underwent concomitant anterior sphincter plication. Crohn group (n = 35): endorectal advancement flap was performed in 8 patients only, a nd 10 with intra- or supraanal stenosis were treated by transperineal approach, 12 (34%) with extended perianal fistula complaints required primary proctectomy, and operative therapy was not possible in 5 with persistent rectal inflammation. No deaths occurred. Postoperatively 12 cases (17%) of suture leakage occurred (flap group (FG): 16.2%, trans perineal group (TPG): 17.6%). Persistent or recurrent fistula occurred in 8 patients (11%), 5.4% FG, 17.6% TPG. Disturbance of continence wa s observed in one patient after endorectal approach. Postoperatively t here were no significant changes in the resting,anal pressure and maxi mum voluntary contraction pressure. A complete primary healing with no further recurrence (follow-up 3 months to 9.5 years) was noted in 78. 4% FG and 64.7% TPG. One patient with postoperative incontinence after the endorectal flap, had undergone anterior levator plication with pe rineal body reconstruction. Conclusions: Endorectal advancement flap a llows preservation of the sphincter and is an effective method for rep air of rectovaginal fistulae. The endorectal advancement flap proved t o result in a better primary healing rate with 85% than the mucosal ad vancement flap with 65%. Perineal procedures are indicated in selected patients with simultaneous sphincter plication and in Crohn's fistula e associated to intra- or supraanal stenosis.