Stapled Endorectal Mucosectomy for High Extrasphincteric Fistula-in-Ano: Preliminary Report

Abstract

There is no optimum surgical method of repair for high extrasphincteric fistula-in-ano. We describe a relatively simple procedure for surgery of extrasphincteric fistula, which entirely preserves the anal sphincter, does not interfere with anal function, and does not preclude the possibility of further surgery, if necessary. Five patients have been treated for high extrasphincteric fistula with a stapled endorectal flap by using a circular hemorrhoidal stapler gun. The procedure involved two 180 degrees pursestrings placed above the dentate line and 3 cm apart, proximal and distal to the internal opening. On firing, the result was the excision of a 180 degrees rectal flap, containing the internal ostium, and including rectal mucosa and submucosa. No perioperative complications were encountered. There was some temporary difficulty in controlling flatus and/or defecatory urgency in two patients, which spontaneously reversed with no treatment within the first two postoperative months. The mean Cleveland Clinic Score of Incontinence did not vary significantly after surgery. Overall anal manometry did not register any significant differences between preoperative and postoperative values. With up to 26 months of follow-up, none of the fistulas recurred. These preliminary promising results suggest that the stapled endorectal flap could have a role in the management of high extrasphincteric fistula-in-ano.