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Advancement Flap Repair: A Good Option for Complex Anorectal Fistulas

Jarrar, Awad M.D.; Church, James M.B.Ch.B.

doi: 10.1097/DCR.0b013e31822d7ddd
Original Contribution

BACKGROUND: Rectal advancement flap is a popular option for treatment of complex anal fistula. Although early outcomes vary, concerns remain about postoperative continence, long-term healing, and its role in patients with Crohn's disease and anovaginal fistulas.

PURPOSE: This study aimed to report long-term outcomes in patients with complex fistula disease.

PATIENTS: Patients who were undergoing rectal advancement flap for anal fistula were included in the study.

DESIGN: Patients were contacted to determine the status of their fistula disease, their bowel function, and their degree of fecal incontinence.

MAIN OUTCOME MEASURES: The main outcomes measured were healing rate and continence.

RESULTS: There were 98 patients, 43 men and 55 women, mean age 53 ± 14 years. Fifty-eight had cryptoglandular fistulas, and 40 (41%) had IBD (33 had Crohn's disease). Seventy-seven of 98 patients had perianal fistulas, and all 77 underwent seton drainage before advancement flap. Twenty-one women had anovaginal fistulas. Average postoperative length of stay was 3 ± 1 days. There were no mortalities. Follow-up was possible in 75 patients, a mean of 7 ± 3 years after surgery. Primary healing occurred in 54 (72%) patients. Twenty-one patients (28%) underwent further treatment, and 12 (57%) healed after a second advancement flap. Four more patients healed after more than 2 flaps or fistulotomy leading to an overall healing rate of 70 of 75 (93%). Patients with Crohn's disease had lower healing rates than those with cryptoglandular fistulas (87% vs 98%). Thirty-two patients (43%) had normal fecal continence before flap, and 43 (57%) had normal fecal continence after flap.

CONCLUSION: Advancement flap is a good option for patients with complex anal fistulas.

Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, Ohio

Financial Disclosures: None reported.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Minneapolis, MN, May 15 to 19, 2010.

Correspondence: James Church, M.B.Ch.B., Desk A 30, 9500 Euclid Ave, Cleveland, OH 44195. E-mail:

© The ASCRS 2011