Advancement Flap Repair Research Articles

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

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. 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. This study was performed as a retrospective review. The study was conducted at the Division of Colon and Rectal Surgery, Erasmus MC, between 2000 and 2012. 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. All patients underwent transanal advancement flap repair. Preoperatively, patients underwent endoanal MRI. 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. 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). Retrospective design, a single surgeon series, and potential selection bias caused by the tertiary referral center status are the limitations of this study. Of all studied variables, horseshoe extension was found to be the only positive predictor of outcome after flap repair for high transsphincteric fistulas.

Treatment of Anal Fistulas With High Intersphincteric Extension

Intersphincteric fistulas with a high upward extension, up to or above the level of the puborectal muscle, in the intersphincteric plane are rare. Most of these fistulas have no external opening and they are frequently associated with a high intersphincteric and/or supralevator abscess. Division of a large amount of internal anal sphincter by extended fistulotomy has a potential risk of diminished fecal continence. The aim of this study was to evaluate flap repair combined with drainage of associated abscesses in high intersphincteric fistulas. This study was performed as a retrospective review. The study was conducted at the Division of Colon and Rectal Surgery, Erasmus MC, between March 1995 and February 2011. Fourteen patients with a cryptoglandular fistula with high intersphincteric extension were included. Transanal advancement flap repair combined with intersphincteric and/or extrasphincteric drainage of associated abscesses was performed. Preoperatively, patients underwent endoanal MRI. Healing was defined as complete wound healing with absence of symptoms. Patients were followed up to assess the recurrence rate and Rockwood fecal continence score. In 1 patient the fistula was not associated with an abscess. In 10 patients the fistula tract ended in a high intersphincteric abscess. Three patients presented with a high intersphincteric abscess and a supralevator abscess. Primary healing was observed in 79% of the patients. The 3 patients without primary healing had a supralevator abscess. In these patients, healing was obtained after a second, third, and fourth procedure. The overall healing rate was 100%. Median postoperative Rockwood score was 0 (range, 0-15). Retrospective design and lack of baseline continence data were the limitations of this study. Since most high intersphincteric fistulas have no external opening and are frequently associated with abscesses, preoperative imaging is useful. Flap repair with adequate drainage of the abscesses is successful, except in fistulas with supralevator extension. However, healing may be achieved by additional procedures.

A New Surgical Device for Minimally Invasive “Core-Out” Excision of High Fistula-in-Ano

Core fistulectomy with endorectal advancement flap repair has been reported as a safe and effective technique for treatment of high fistula-in-ano. A number of rigid and flexible fistulectomy sets have already been fabricated pursuing the objectives of facilitating the procedure of this conservative surgical technique and reducing its risks of continence impairment. Two different methods (the method of scraping the granulation tissue of fistula and the method of separating and removing a thin layer from inside of tract) have been served in these sets for obliterating the abnormalities. In this work, with the aim of minimizing invasion to healthy tissue encircling the fistula, specially sphincter muscles, we designed and fabricated a new flexible fistulectomy device, which uses the second mentioned method. The new set separates an approximately 2.5-mm-thick layer from inside of the fistulous tract, by rotating a special tubular blade around its axis and moving the blade along the fistulous tract from external orifice toward the internal orifice. At the same time, the separated tissue may be removed from the fistulectomy lumen by rotating a special cannulated screw embedded coaxially inside the tubular blade. A flexible guidewire was used for identifying the tract path and guiding the device along it. We used the new set for excising 10 curved fistula models of approximately 16 cm length and 1.5 mm diameter, which were created in cubic pieces of fresh cow muscle as test specimens. After removing the device, each specimen was left with a smooth-walled lumen of approximately 9 mm diameter. The tubular blade works very well in separating a thin layer from inside of the fistula models and the cannulated screw is capable of easily removing the separated tissue. The removed tissue could be used as a sample of the whole tract for histopathological examinations. The screw and flexible guidewire lead the blade along the tract in a good manner and ensure circumferential separation of the fistula. With regard to the results of our tests, it is anticipated that the new set is an efficient instrument for easy, safe and fast core-out excision of high anal fistulas and is able to reduce the risk of injuries to healthy tissue encircling the fistulous tract.

Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn’s disease

It was the aim of this prospective study to analyze both the feasibility and preliminary results of video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair for complex fistulas in Crohn's disease. All patients with perianal Crohn's disease suffering from complex fistulas who underwent definitive surgery using VAAFT combined with advancement flap repair were prospectively enrolled in the study. Only complex fistulas with concurrent stable disease and without any evidence of severe inflammatory activity or perianal sepsis were treated using the VAAFT technique. Patients with Crohn's proctitis or prior proctectomy were not candidates for the procedure. VAAFT was performed by using the VAAFT equipment (Karl Storz, Tuttlingen, Germany). Key steps included visualization of the fistula tract and/or side tracts using the fistuloscope and correct localization of the internal fistula opening under direct vision with irrigation. Diagnostic fistuloscopy was followed by advancement flap repair. In addition to feasibility, primary end points included detection of side tracts, success and continence status (assessed by the Cleveland Clinic Incontinence Score). Success was defined as closure of both internal and external openings, absence of drainage without further intervention and absence of abscess formation. Follow-up information was derived from clinical examination 3, 6 and 9 months postoperatively. Within a 3-month observation period (September to November 2011), VAAFT was attempted in 13 patients with Crohn's associated complex fistulas. The completion rate was 85% (11/13). In these 11 patients (median age 34 years, 64% females), complex fistulas were transsphincteric (8), suprasphincteric (2) and recto-vaginal (1). Forty-six percent (5/11) had concomitant therapy with biologic drugs. In 36% (4/11), VAAFT was performed with fecal diversion. Median duration of surgery was 22 (range 18-42) minutes. Using VAAFT, additional side tracts not detected preoperatively could be identified in 64% (7/11). No morbidity occurred. After a mean follow-up of 9 months, the success rate was 82% (9/11). No deterioration of continence was documented (Cleveland Clinic Incontinence Score 2.4 vs. 1.6, p > 0.05). Preliminary results of the addition of the VAAFT technique to advancement flap repair in Crohn's fistulas demonstrate that this leads to a high identification rate of occult side tracts with encouraging short-term healing rates. Moreover, a completion rate of 85% seems promising.

Usefulness of V-Y Advancement Flap for Defects after Skin Tumor Excision

BackgroundAfter skin tumor excision on the face, extremities, or trunk, the choice of treatment for a skin defect is highly variable. Many surgeons prefer to use a local flap rather than a skin graft or free flap for small- or moderately-sized circular defects. We have used unilateral or bilateral V-Y advancement flaps, especially on the face. Here we evaluated the functional and aesthetic results of this technique.MethodsAll of the patients were pathologically diagnosed with squamous cell carcinoma (SCC), basal cell carcinoma (BCC), or malignant melanoma or premalignant lesion (Bowen's disease). Thirty-two patients underwent V-Y advancement flap repair (11 unilateral and 21 bilateral) from January 2007 to June 2011. We analyzed the patients' age and satisfaction, and location and size of defect. The patients were followed up for 6 months or more.ResultsThere were 22 women and 10 men. The ages ranged from 47 to 93 years with a mean age of 66 years. The causes were SCC in 15 cases, BCC in 13 cases, malignant melanoma in 1 case, Bowen's disease in 2 cases, and another cause in 1 case. The tumor locations were the face in 28 patients, and the scalp, upper limb, and flank each in one patient. All of the flaps survived and the aesthetic results were good. Postoperative recovery was usually rapid, and no complication or tumor recurrence was observed.ConclusionsThe V-Y advancement flap is often used not only for facial circular defects but also for defects of the trunk and extremities. Its advantages are less scarring and superior aesthetic results as compared with other local flap methods, because of less scarification of adjacent tissue and because it is an easy surgical technique.

Assessment of microbiota and peptidoglycan in perianal fistulas

Transanal advancement flap repair has been advocated as the treatment of choice for high transsphincteric perianal fistulas, but fails in 1 of every 3 patients. Persistence of the fistula after flap repair might be the result of ongoing disease in the remaining fistula tract. In 10 specimens of the distal part of the fistula, microbiota was assessed by means of conventional microbiological culture and 16S rRNA gene sequencing. Proinflammatory bacterial peptidoglycan and recognition proteins were assessed by immunohistochemistry. Bacterial species were bowel derived, skin derived, or a combination of both. No mycobacterium species were identified. 16S rRNA gene sequencing failed to identify bacteria in all but 1 specimen, most likely as a result of low numbers of organisms. Peptidoglycan was detected in 90% of the patients, and a host response to peptidoglycan in 60%. Therefore, we suggest that peptidoglycan might play a role in the ongoing inflammation in perianal fistulas.

Outcomes Following V-Y Advancement Flap Reconstruction of Large Upper Lip Defects

To characterize revision surgery following V-Y subcutaneous tissue pedicle advancement flap repair of large upper lip skin defects. Retrospective review of upper lip skin defects at least 3.0 cm(2) in area that were reconstructed with a V-Y subcutaneous tissue pedicle advancement flap at an academic tertiary care center. Depth and area of the defect, as well as involvement of the vermilion and nasal ala, were recorded as independent variables. Revision techniques were analyzed to identify patterns. Thirty patients were identified as having upper lip skin defects with a mean (range) area of 7.0 (3.0-14.0) cm(2) (median, 6.25 cm(2)). The defect involved the nasal ala in 4 cases and the vermilion in 3 cases. At least 1 revision surgery was performed in 14 patients (47%). Alar or vermilion involvement was a significant factor in revision by χ(2) analysis (P = .03). Larger defect size did not predict a need for revision, even among cases where the defect did not involve the ala or vermilion (P = .68). Reconstruction of large upper lip skin defects with a V-Y subcutaneous tissue pedicle advancement flap is associated with a 47% revision rate, and when the defect involves the ala or vermilion, the revision rate is increased. Defect size alone cannot be used to predict the need for revision surgery. Revision techniques are demonstrated.

Is It Possible to Improve the Outcome of Transanal Advancement Flap Repair for High Transsphincteric Fistulas by Additional Ligation of the Intersphincteric Fistula Tract?

Transanal advancement flap repair is successful in 2 of every 3 patients with a cryptoglandular fistula passing through the middle or upper third of the external anal sphincter. It has been suggested that ongoing disease in the remaining fistula tract contributes to failure. Ligation of the intersphincteric fistula tract might be a useful tool to eradicate this ongoing disease. The aim of the present study was to evaluate the effect of an additional ligation of the fistula tract on the outcome of transanal advancement flap repair. This investigation was designed as a prospective clinical study. The study took place in a university hospital. A consecutive series of 41 patients with a high transsphincteric fistula of cryptoglandular origin were included. Ligation of the intersphincteric fistula tract was performed in addition to flap repair. Early and late complications were recorded. Continence scores were determined with the use of the Fecal Incontinence Severity Index. Median duration of follow-up was 15 months. Primary healing was observed in 21 patients (51%). Of the 20 patients with a failure, the original transsphincteric fistula persisted in 12 patients. In 8 patients, the transsphincteric fistula was converted into an intersphincteric fistula. These patients underwent subsequent fistulectomy, which was successful in all of them. The overall healing rate was 71%. This was a preliminary observational study with no control group. : The ligation of the intersphincteric fistula tract procedure is prone to infection and does not enhance the outcome of flap repair.

Identification of epithelialization in high transsphincteric fistulas

BackgroundAt present, transanal advancement flap repair (TAFR) is the treatment of choice for transsphincteric fistulas passing through the upper and middle third of the external anal sphincter. It has been suggested that epithelialization of the fistula tract contributes to the failure of the treatment. The aim of this study was to assess the prevalence of epithelialization of the fistula tract and to study its effect on the outcome of TAFR and TAFR combined with ligation of the intersphincteric fistula tract (LIFT).MethodsForty-four patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Nine of these patients underwent a combined procedure of TAFR with LIFT. In all patients the fistula tract was excised from the external opening up to the outer border of the external anal sphincter. In patients undergoing TAFR combined with LIFT an additional central part of the intersphincteric fistula tract was excised. A total of 53 specimens were submitted. Histopathological examination of the specimens was carried out by a pathologist, blinded for clinical data.ResultsEpithelialization of the distal and intersphincteric fistula tract was observed in only 25 and 22% of fistulas, respectively. There was no difference in outcome between fistulas with or without epithelialization.ConclusionsEpithelialization of high transsphincteric fistulas is rare and does not affect the outcome of TAFR and TAFR combined with LIFT.

Is the Outcome of Transanal Advancement Flap Repair Affected by the Complexity of High Transsphincteric Fistulas?

Transanal advancement flap repair for the treatment of high transsphincteric fistulas fails in 1 of every 3 patients. Until now no definite risk factors for failure have been identified. The question is whether the more complex fistulas, such as those with horseshoe extensions and associated abscesses, have a less favorable outcome. Aim of the present study was to indentify whether more complex fistulas have a less favorable outcome. This study is a retrospective case series review. Between 1995 and 2007 a series of 162 patients underwent endoanal MR imaging before transanal advancement flap repair. Two investigators, without prior knowledge of the surgical findings, reviewed all MR images. Lateral fistulas were identified in 5 patients. Because of the small number, these patients were excluded from further analysis. Posterior fistulas were identified in 119 patients (76%). These fistulas had 3 types of extensions: a direct course (36%), a classic horseshoe extension (23%), or an intersphincteric horseshoe extension (41%). The corresponding healing rates were 37%, 81%, and 73%. Anterior fistulas were observed in 23% of the patients. These fistulas had 2 types of extensions: a direct course (61%) or a classic horseshoe extension (39%). The corresponding healing rates were 60% and 52%. The healing rate of fistulas with a direct course was significantly lower than the healing rate of fistulas with a classic or intersphincteric horseshoe extension. Associated abscesses were found in 47% of the posterior fistulas and 5% of the anterior fistulas. Once adequately drained, these abscesses did not affect the outcome of transanal advancement flap repair. The complexity of high transsphincteric fistulas does not affect the outcome of transanal advancement flap repair.

Obesity is a negative predictor of success after surgery for complex anal fistula

BackgroundIt was the aim of this study to compare the outcome of surgery for complex anal fistulas in obese and non-obese patients.MethodsAll patients with complex anorectal fistulas who underwent fistulectomy and/or rectal advancement flap repair were prospectively recorded. Surgery was performed in a standardized technique. Body mass index (BMI [kg/m2]) was used as objective measure to indicate morbid obesity. Patients with a BMI greater than 30 were defined as obese, and patients with a BMI below 30 were defined as non-obese. The parameters analyzed related to BMI included success or failure, and reoperation rate due to recurrent abscess. Success was defined as closure of both internal and external openings, absence of drainage without further intervention, and absence of abscess formation.ResultsWithin two years, 220 patients underwent advancement flap repair and met the inclusion criteria. 55% of patients were females, mean age was 39 (range 18-76) years, and the majority of fistulas were located at the posterior site. 69% of patients (152/220) were non-obese (BMI < 30), whereas 31% (68/220) were obese (BMI > 30). After a median follow-up of 6 months, primary healing rate ("success") for the whole collective was 82% (180/220). Success was significantly different between non-obese and obese patients: In non-obese patients, recurrence rate was significantly lower than in obese patients (14% vs. 28%; p < 0.01). Moreover, reoperation rate due to recurrent abscess with the need for seton drainage in the failure groups was significantly higher in obese patients when compared to non-obese patients (73% vs. 52%; p < 0.01). Using multivariate analysis, obesity was identified as independent predictive factor of success or failure (p < 0.02).ConclusionObese patients are at higher risk for failure after surgery for complex anal fistula.

Endorectal Advancement Flap Repair in Patients With Crohn's Disease: A Word of Caution!

Zimmerman, David D. E. M.D., Ph.D.; Pronk, Apollo M.D., Ph.D., E.B.S.Q. Author Information

Seton drainage in high anal fistula

Dear Editor: We read the article “Seton drainage prior to transanal advanced flap repair: useful or not?” by Mitalas et al. (Int J Colorectal Dis. 2010; 25: 1499–502) with great interest. This retrospective study touches an important issue in the management of high anal fistulas. The seton drainage prior to transanal advancement flap repair (TAFR) is performed if there is an associated high blind tract or supralevator abscess. The aim of this seton is to allow drainage of pus and to control ongoing infection. Subsequently, patient undergoes TAFR or anocutaneous advancement flap repair after subsidence of pus discharge. This retrospective study compares healing rates of TAFR in two groups, with or without prior seton drainage (68 vs. 210 patients). Authors assumed that selection bias in their study is negligible as there was no difference in the baseline characteristics of these two groups. The authors have not mentioned data regarding abscesses associated with fistula. The comparison of baseline characteristics of these two groups also does not take into account of presence or absence of abscesses. Moreover, they assumed that prior seton drainage was done by referring surgeons in order to bide time which may not be true as only a part of referred patients had seton drainage. It could be possible that referring surgeon had placed seton selectively in cases with associated sepsis. Author‘s conclusion that prior seton drainage in TAFR is not useful seems oversimplification of this complex issue. Deep-seated abscesses are frequently associated with high transphincteric and suprasphincteric fistulas. Value of prior seton drainage in these selected cases cannot be belittled. We believe that randomized controlled trial is highly desired at this moment to settle this critical issue of seton drainage. Conflict of issue: Nil

The Anal Fistula Plug as an Adjunct to Transanal Advancement Flap Repair

The Anal Fistula Plug as an Adjunct to Transanal Advancement Flap Repair

Incidence, Clinical Symptoms and Management of Rectourethral Fistulas After Radical Prostatectomy

Rectourethral fistula is a rare but severe complication after radical prostatectomy and there is no standardized treatment. We retrospectively evaluated the incidence, symptoms and management of rectourethral fistulas based on our experience. From 1999 to 2008 we performed 2,447 radical prostatectomies. Patients in whom postoperative rectourethral fistulas developed were identified. Based on the therapeutic approach patients were categorized into group 1-conservative treatment, group 2-colostomy with or without surgical closure and group 3-immediate surgical closure without colostomy. Rectourethral fistulas developed in 13 of 2,447 patients (0.53%) after radical prostatectomy. The risk of rectourethral fistulas was 3.06-fold higher (p = 0.074) for perineal (7 of 675, 1.04%) than for retropubic prostatectomy (6 of 1,772, 0.34%). In 7 of 13 patients (54%) a rectal lesion was primarily closed at radical prostatectomy. Median followup was 59 months. In all patients in group 1 (3) the fistula closed spontaneously with conservative treatment. None of these patients had fecaluria. In group 2 of the 9 patients 3 (33%) experienced spontaneous fistula closure after temporary colostomy and transurethral catheterization. In this group 6 patients (67%) required additional surgical fistula closure, which was successful in all. Surgical fistula closure (1) without colostomy in presence of fecaluria failed (group 3). The therapeutic concept for rectourethral fistulas should be guided by clinical symptoms. Rectal injury during radical prostatectomy is a major risk factor. In cases with fecaluria colostomy is required for control of infection and may allow spontaneous fistula closure in approximately a third of cases. In the remainder of cases surgical fistula closure was successful in all after protective colostomy.

Required length of follow‐up after transanal advancement flap repair of high transsphincteric fistulas

Repair of high perianal fistulas presents a major surgical challenge. Transanal advancement flap repair (TAFR) provides a useful tool in the treatment of these fistulas. Initially promising results have been reported. More recent studies indicate that TAFR fails in one out of three patients. The aim of the present study was to determine the appropriate length of follow-up needed to assess the healing rate after TAFR of high transsphincteric fistulas. Between 1992 and 2000 a consecutive series of 80 patients with a high transsphincteric fistula of cryptoglandular origin underwent TAFR. Medical records of all patients were studied. The initial healing rate and the median healing time were assessed. The initial outcome was successful in 54 patients. The medical records revealed that only one of these patients presented with a recurrent fistula after 28 months. The other 53 patients were sent a questionnaire in 2006 aimed to determine whether they had any complaints or signs of a recurrent fistula. The initial healing rate was 68%. The median healing time was 3.6 months. The completed questionnaire was returned by 48 patients. None of these patients reported any complaints or signs of a recurrent fistula. Median duration of follow-up in these patients was 92 months. At a median time interval of 3.6 months fistula healing was observed in 54 patients (68%). Only one patient (2%) encountered a recurrence. The length of follow-up can be restricted to the healing time.

Does Rectal Mucosal Blood Flow Affect the Outcome of Transanal Advancement Flap Repair?

Transanal advancement flap repair provides a useful tool for the treatment of high transsphincteric fistulas. Recent studies indicate that transanal advancement flap repair fails in one of every three patients. Until now no definite risk factors for failure have been identified. A previous pilot study, conducted in our own institution, revealed a significant decrease in rectal mucosal blood flow after creation of the advancement flap. We postulated that impaired blood flow might result in breakdown of the distal part of the flap. This study was designed to evaluate the effect of rectal mucosal blood flow on the outcome of transanal advancement flap repair. Between August 2004 and June 2007 a series of 54 patients with a high transsphincteric fistula underwent transanal advancement flap repair. The present series comprised 34 males and 20 females. Median age at the time of repair was 45 (range, 25-68) years. Rectal mucosal blood flow was determined by laser Doppler flowmetry before and after creation of the flap. The flow was expressed in arbitrary units. Transanal advancement flap repair was successful in 34 patients (63%). Median healing time was 2.2 months. Median mucosal blood flow before and after transanal advancement flap repair was 145 arbitrary units and 94 arbitrary units, respectively. This decrease was statistically significant. In a comparison of patients with and patients without a successful repair, no differences were found in mucosal blood flow before and after creation of the flap (146 vs. 138 arbitrary units and 83 vs. 104 arbitrary units). Rectal mucosal blood flow does not affect the outcome of transanal advancement flap repair.

Adverse Effect of BioGlue® on the Outcome of Transanal Advancement Flap Repair

Adverse Effect of BioGlue® on the Outcome of Transanal Advancement Flap Repair

Anal Fistula Plug: A European Perspective

Impressed by the initial success rates (80%) of the Cook Surgisis AFP anal fistula plug for the closure of both cryptoglandular and Crohn's associated anorectal fistulas, the preliminary results from Europe showed healing rates of 41% and 61%, respectively. However, no impairment of continence was documented. Analyzing the current experiences of the plug procedure from a German perspective, a variety of issues are under debate including the role of bowel preparation, treatment of fistula tract, closure of the internal opening, postoperative management, and, finally, financial reimbursement. Furthermore, the ideal indication has to be defined. In general, the introduction of the plug has accelerated a new discussion on the optimal treatment of high anorectal fistulas. Further analysis is needed to explain the definite role of this innovative technique in comparison to traditional surgical techniques, particularly whether the plug can offer the biological properties required for permanent fistula healing. Consequently—as a European perspective—the randomized German multicenter study comparing the plug procedure vs. advancement flap repair for transsphincteric fistulas will hopefully elucidate the definite role of the plug.

Obliteration of the fistulous tract with BioGlue® adversely affects the outcome of transanal advancement flap repair

Transanal advancement flap repair (TAFR) is useful in the treatment of high transsphincteric fistulas. Initially, promising results were reported. More recent studies have indicated that TAFR fails in one out of three patients. In almost all of our patients with a failure, we have observed healing of the flap except at the site of the original internal opening. A possible explanation for this remarkable finding might be persistent inflammation in the fistulous tract, finding a way out through the original internal opening. The question is whether obliteration of the fistulous tract by local installation at a surgical adhesive, can prevent persistent inflammation to break through the original opening. The aim of this pilot study was to investigate whether concomitant instillation of BioGlue could improve the healing rate following TAFR for high transsphincteric fistulas. Between March 2006 and April 2006 a consecutive series of eight patients (four men, four women; median age 46 years) with a high transsphincteric fistula underwent TAFR after instillation of BioGlue in the fistulous tract. All patients were seen in the outpatient department for postoperative evaluation. Fistula healing was observed in only one patient (12.5%). All other patients experienced one or more of the following complications: prolonged severe pain (n=5), discharge of great amounts of purulent liquid from the external opening (n=3) and abscess formation (n=2), necessitating incision and drainage. Because of this unexpected outcome we decided to terminate the study prematurely. Our findings indicate that obliteration of the fistulous tract with BioGlue adversely affects the outcome of TAFR for high transsphincteric fistulas.