Transanal advancement flap repair of transsphincteric fistulas

OBJECTIVE: The purpose of this study was to evaluate the healing rate of tr anssphincteric perianal fistulas after transanal advancement flap repair an d to examine the impact of this procedure on fecal continence. METHODS: Bet ween January 1992 and January 1997, 44 consecutive patients with a transsph incteric perianal fistula passing through the middle or upper third of the external anal sphincter underwent transanal advancement flap repair. There were 34 male patients, and the median age was 44 (range, 19-72) years. Twen ty-four patients (55 percent) had previously undergone one or more prior at tempts at repair. With the patient in prone jackknife position, the interna l opening of the fistula was exposed using a Parks retractor. The crypt-bea ring tissue around the internal opening and the overlying anoderm was excis ed. A layer of mucosa, submucosa, and internal sphincter fibers was mobiliz ed 4 to 6 cm proximally. The base of the flap was approximately twice the w idth of its apex. The flap was advanced and sutured to the anoderm below th e level of the internal opening. The median follow-up was 12 months. Fecal continence was evaluated in 43 patients by means of a questionnaire. RESULT S: Transanal advancement nap repair was successful in 33 patients (75 perce nt). Success was inversely correlated with the number of prior attempts. In patients with no or only one previous attempt at repair the healing rate w as 87 percent. In patients with two or more previous repairs the healing ra te dropped to 50 percent. In 15 patients (35 percent) continence deteriorat ed after transanal advancement flap repair. Twenty-six patients (59 percent ) had a completely normal continence preoperatively. Ten of these patients (38 percent) encountered soiling and incontinence for gas after the procedu re, whereas three subjects (12 percent) complained of accidental bowel move ments. Eighteen patients (41 percent) had continence disturbances at the ti me of admission to our hospital. In two of these patients (11 percent), inc ontinence deteriorated. CONCLUSIONS: The results of transanal advancement f lap repair in patients with no or only one previous attempt at repair are g ood. In patients who have undergone two or more previous attempts at repair the outcome is less favorable. Remarkably, the number of previous attempts did not adversely affect continence status.