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Predictors of Outcome After Transanal Advancement Flap Repair for High Transsphincteric Fistulas

van Onkelen, Robbert S. M.D., M.Sc.1,2; Gosselink, Martijn P. M.D., Ph.D.3; Thijsse, Sjoerd M.D.1; Schouten, Willem R. M.D., Ph.D.1

doi: 10.1097/DCR.0000000000000154
Original Contributions: Anorectal Disease

BACKGROUND: Transanal advancement flap repair fails in 1 of every 3 patients with a high transsphincteric fistula. It has been reported that smoking, obesity, and previous attempts at repair adversely affect the outcome of transanal advancement flap repair. Because these findings could not be confirmed by other studies, it is still unclear whether these and other factors have an impact on the outcome.

OBJECTIVE: The aim of this study was to identify predictors of outcome in a large cohort of patients who underwent transanal advancement flap repair for a high transsphincteric fistula.

DESIGN: This study was performed as a retrospective review.

SETTINGS: The study was conducted at the Division of Colon and Rectal Surgery, Erasmus MC, between 2000 and 2012.

PATIENTS: A consecutive series of 252 patients with a high transsphincteric fistula of cryptoglandular origin were included. Patients with a rectovaginal or Crohn fistula were excluded.

INTERVENTIONS: All patients underwent transanal advancement flap repair. Preoperatively, patients underwent endoanal MRI.

MAIN OUTCOME MEASURES: Healing was defined as complete wound healing with absence of symptoms. Patients were followed up to assess failure. Seventeen patient- and fistula-related variables were assessed.

RESULTS: Median duration of follow-up was 21 months (range, 6–136 months). The failure rate at 3 years was 41% (95% CI, 34–48). None of the studied variables predicted the outcome of flap repair except horseshoe extension. In univariate and multivariate analyses, significantly less failures were observed in patients with a horseshoe extension (p < 0.05).

LIMITATIONS: Retrospective design, a single surgeon series, and potential selection bias caused by the tertiary referral center status are the limitations of this study.

CONCLUSIONS: Of all studied variables, horseshoe extension was found to be the only positive predictor of outcome after flap repair for high transsphincteric fistulas.

1Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands

2Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands

3Department of Surgery, Oxford University Hospitals, Oxford, United Kingdom

Financial Disclosure: None reported.

Presented at the meeting of the European Society of Coloproctology, Belgrade, Serbia, September 25 to 27, 2013.

Correspondence: Willem R. Schouten, M.D., Ph.D., Erasmus Medical Center Rotterdam, Division of Colon and Rectal Surgery, Department of Surgery, H 181, ‘s Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands. E-mail:

© 2014 The American Society of Colon and Rectal Surgeons