Mucosal Advancement Flap Research Articles

MP56-19 PROMISING PRELIMINARY RESULTS FOR VENTRAL ONLAY BUCCAL MUCOSAL GRAFT URETHROPLASTY IN FOSSA NAVICULARIS STRICTURES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III (MP56)1 Sep 2021MP56-19 PROMISING PRELIMINARY RESULTS FOR VENTRAL ONLAY BUCCAL MUCOSAL GRAFT URETHROPLASTY IN FOSSA NAVICULARIS STRICTURES Alejandra Perez, Adam Nolte, Chase Mallory, Scott Jamieson, Jessica Boyer, Dhaval Jivanji, Spencer Liem, George Wayne, and Billy Cordon Alejandra PerezAlejandra Perez More articles by this author , Adam NolteAdam Nolte More articles by this author , Chase MalloryChase Mallory More articles by this author , Scott JamiesonScott Jamieson More articles by this author , Jessica BoyerJessica Boyer More articles by this author , Dhaval JivanjiDhaval Jivanji More articles by this author , Spencer LiemSpencer Liem More articles by this author , George WayneGeorge Wayne More articles by this author , and Billy CordonBilly Cordon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002086.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nearly twenty percent of all anterior urethral strictures occur at the fossa navicularis (FN). Management balances restoring urethral patency while maintaining adequate cosmesis. Historically, FN strictures are often managed via glans cap or glans wings, and in severe cases, multi-stage procedures. Augmentation with ventral onlay buccal mucosal grafts (VOBMG) has been traditionally discouraged for fear of poor graft support and risk of fistula formation. METHODS: We retrospectively reviewed clinical and procedural characteristics for all patients with FN strictures that underwent urethroplasty at our institution from August 2016 through February 2021. Our approach included a ventral incision from the meatus to corona leaving a dorsal strip of native urethra to which BMG graft is anastomosed over a 20-24F catheter. A glansplasty is then performed to support the graft. Outcomes included recurrence rates and complication rates. RESULTS: We identified 14 patients that underwent urethroplasty for isolated fossa navicularis strictures. Of these, 9 underwent a single stage VOBMG urethroplasty. Other approaches included staged Johansson repair, mucosal advancement, and fasciocutaneous flaps with glans cap, which were excluded from analysis. Average follow up period to date was 25.8 months. 1/9 (11%) developed a stricture recurrence requiring intervention with balloon dilation, after which there has been no further recurrence at 20 months follow-up. No UTIs, fistulae, or other complications were seen. CONCLUSIONS: Our research demonstrates that single-stage VOBMG is an effective means of treating FN strictures. Despite a limited number of cases, our series demonstrates promising short-term safety and efficacy for this procedure, carrying significant advantages over dilation and staged reconstruction. We observed good graft take, successful cosmetic and functional outcomes and no evidence of urethra-cutaneous fistulas. Further series follow-up and comparative data will help to elucidate durability of outcome and refine treatment options. Source of Funding: n/a © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e976-e976 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alejandra Perez More articles by this author Adam Nolte More articles by this author Chase Mallory More articles by this author Scott Jamieson More articles by this author Jessica Boyer More articles by this author Dhaval Jivanji More articles by this author Spencer Liem More articles by this author George Wayne More articles by this author Billy Cordon More articles by this author Expand All Advertisement Loading ...

Endonasal Septal Perforation Repair: Free Mucosal Graft With Lyoplant® Bioscaffold

Nasal septal perforation (NSP) is a common complication of nasal surgery and can cause nasal obstruction, crust, and epistaxis. Many surgical methods have been introduced for repair of NSP, among which mucosal flap and artificial dermis have been widely used. However, mucosal graft can shrink and migrate and is difficult to fix at the perforation site. Mucosal advancement flap requires a wide extent of septal mucosa dissection, and artificial dermis can cause nasal obstruction because of its bulkiness and lower biocompatibility than autologous mucosa. To overcome these problems, we reported successful outcomes in 4 cases of small NSP by free mucosal graft with bioscaffold.

Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands

BackgroundManagement of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands.MethodsDutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA.ResultsIn total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%).ConclusionsDutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.

Application of three-staged paramedian forehead flap in reconstruction and repair of full-thickness nasal defect

Objective: To evaluate the application of three-staged paramendian forehead flap technique in reconstruction of severe full-thickness nasal defect. Methods: Clinical data of 7 cases with nasal reconstruction by three-staged forehead flap technique in the First Affiliated Hospital of Xinjiang Medical University and HongKong University Shenzhen Hospital between June 2016 and October 2019 was retrospectively reviewed. All were males aged from 10 to 71 years. There were 4 cases of basal cell carcinoma of the external nose, 2 cases of traumatic nasal defects and 1 case of large rhinophyma. All the operations were performed with the paramedian forehead flap in three stages. In stage Ⅰ, full layered forehead flap was transposed to the nasal detect. Lining flaps were reconstructed with folded forehead skin (n=4), turn-over flap plus septal chondro mucosal pivotal flap (n=2), or bipedicled vestibular skin and nasal mucosa advancement flap (n=1). According to the reconstruction mode of the lining flaps, whether to implant cartilage to reconstruct the external nasal stent at stage Ⅰ was determined. At stage Ⅱ, the folded flaps were partly or completely separated from the covering flaps along the free edges of nasal alar. All the excess soft tissue including subcutaneous fat and frontalis muscle were excised, cartilage grafts were placed or sculpted to make an ideal nasal contour. The covering flaps were then returned on the recontoured, three-dimensional recipient bed. At stage Ⅲ, the pedicles were divided. Descriptive statistical method was used to analyze the data. Results: In all cases, restoration of the nasal contour was remarkably good, no flap necrosis occurred. All patients were followed up for 6 months to 2 years, and the appearance and function of the nose recovered well. All patients were satisfied with their final aesthetic results. Conclusions: Three-staged paramedian forehead flap technique ensures maximal blood supply for the lining flap and the inserted cartilage graft, and restores an ideal three-dimensional nasal contour for reconstruction of large full thickness nasal defects.

Use of the OVESCO OTSC® Proctology Clip for closure of fistula-in-ano at Wits Donald Gordon Medical Centre - a single centre experience

Definitive closure of fistula-in-ano poses an ongoing surgical challenge. The OVESCO OTSC® Proctology Clip (proctology clip) purports to offer improved preservation of the anal sphincter whilst at the same time curing the fistula by closure. A retrospective record review was conducted for patients who received the proctology clip as part of the management of fistula-in-ano in the Colorectal Unit at Wits Donald Gordon Medical Centre (WDGMC). There were 19 cases of fistula-in-ano treated with the proctology clip. All were cryptoglandular in origin. The median age was 50 years (IQR 44-56 years) and post-procedure, the median follow-up duration was 145 days (IQR 63-298 days). Overall, 9 procedures were successful (47%). Success rates were higher for simple (66.7%) as opposed to complex (38.5%) fistula-in-ano. For patients who underwent placement of the proctology clip as a primary procedure, the success rate (50%) was slightly better than those who received the clip as a secondary procedure (44.4%). This preliminary data presents our initial experience using the proctology clip. While these data may serve as a "proof of concept", a multi-centre controlled trial comparing this method to the rectal mucosal advancement flap (RMAF) is needed to determine the role of the proctology clip in the management of fistula-in-ano.

Comparison of the Efficacy of the Various Treatment Modalities in the Management of Perianal Crohn's Fistula: A Review.

Crohn's disease (CD) is a transmural inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal (GI) tract. With the disease's progression, adhesions and transmural fissuring, intra-abdominal abscesses, and fistula tracts may develop. An anal fistula (or fistula-in-ano) is a chronic abnormal epithelial lined tract communicating the anorectal lumen (internal opening) to the perineal or buttock skin (external opening). The risk of fistula development varies from 14%-38%. It can cause significant morbidity, which adversely impacts the quality of life. It is mostly believed that an anal crypt gland infection causes anal abscesses, leading to fistula development. Crohn's disease's pathogenesis involves Th1 and Th17 hypersensitivity due to an unknown antigen within the intestinal mucosa.Evidence to support this review was gathered via the Pubmed database. Search terms used were combinations of "Perianal fistula," "seton," "immunotherapy." Studies were reviewed and cross‐referenced for additional reports.Setons are surgical thread loops passed from the external to the internal opening of the fistula tract and exteriorized through the anorectal canal, facilitating abscess drainage and inciting a local inflammatory reaction, thus promoting the resolution of the fistula. Biologicals such as anti-tumor necrosis factor (TNF) antibody (infliximab, adalimumab, certolizumab), anti-IL-12/23 (ustekinumab), and anti-α₄β₇ integrin antibody (vedolizumab) have been approved for Crohn's disease targeting the Th1/Th17-mediated inflammation. Other therapeutic modalities are fistulotomy, cyanoacrylate glue, bioprosthetic plugs, mucosal advancement flap, ligation of inter-sphincteric fistula tract (LIFT), diverting stoma, proctectomy, video-assisted anal fistula treatment (VAAFT), and fistula laser closure (FiLaC).Our review found that chronic seton therapy should be the primary approach, especially if the patient has a perianal abscess. It has a low incidence of re-intervention, recurrent abscess formation, and side-branching of the fistulous tract, with preservation of the fistulous tract's patency and cost-effectiveness. The major disadvantage of seton therapy is the discomfort and time to achieve stability. Among the biologicals, infliximab is the only therapy which has a statistically significant effect on the healing rate of perianal Crohn's fistula compared to placebo, but the major disadvantage associated with anti-TNF as sole therapy is high re-intervention rate, prolong maintenance therapy, high recurrence rate, and severe side effects. We hypothesize that the two aspects should be addressed concurrently to increase the fistula healing or closure rate. First, the seton should be used as initial therapy to maintain tract patency to allow abscess drainage and minimize the intestinal flora colonization within the tract mucosa, thereby leukocytic infiltration and propagation of inflammation within the tract. The second aspect that has to be considered is that we should target the initial stimulation of the Th1/Th17 mediated hypersensitivity instead of a factor/cytokine involved in the inflammation mediation. Although the unknown antigen triggering such hypersensitivity is not clear, we could target the RAR-related orphan receptor γ (RORγ)-T (transcription factor involved in activation of Th17 cells) and the T-bet (transcription factor involved in activation of Th17 cells) within the GI mucosa by a novel target immune therapy.

Posterior Based Triangular Mucosal Advancement Flap for Surgical Correction of Scleroderma-Induced Microstomia.

Systemic sclerosis is a complex autoimmune connective tissue disease of unknown cause that causes sclerosis and inflammation of the skin and subcutaneous tissue. Sclerosis involving the face can lead to microstomia, leading to difficulties with mastication, phonation, and oral hygiene. Although many agents have been used to treat internal organ involvement, they often have compromised efficacy on cutaneous manifestation including facial dermal sclerosis. In this case presentation, we will introduce a surgical technique to correct scleroderma-induced microstomia.

Posterior glottic stenosis: management and outcomes

Pediatric posterior glottic stenosis (PGS) is a challenging clinical entity with multiple treatment options. This review describes the evaluation of patients with PGS and discusses existing surgical techniques. PGS secondary to a distinct scar band between the vocal folds can often be effectively managed with endoscopic division and surveillance. More advanced glottic scarring that also involves the interarytenoid mucosa, cricoarytenoid joints, or subglottis merits a more thorough investigation and repair. A postcricoid mucosal advancement flap can be employed in select adolescent or adult PGS, but long-term cricoarytenoid joint mobility is difficult to restore once it has been fixed. Younger pediatric patients have smaller airways and frequent concurrent subglottic stenosis which is better addressed with cartilage grafting. Surgical success in pediatric PGS depends on careful preoperative airway assessment and the accurate characterization of airway stenosis. A surgical technique should be chosen based on the severity and extent of stenosis.

Turbinate stitch: modification of Ahmed’s three-layered flap for oroantral fistulas. A technical note

Oroantral fistula is a communication between the maxillary sinus and the oral cavity. According to the literature, dental extraction is the most common cause, followed by maxillary cysts, benign or malignant lesions, and trauma. 1 Güven O. A clinical study on oroantral fistulae. J Craniomaxillofac Surg. 1998; 26: 267-271 Crossref PubMed Scopus (75) Google Scholar , 2 Yilmaz T. Suslu A.E. Gursel B. Treatment of oroantral fistula: experience with 27 cases. Am J Otolaryngol. 2003; 24: 221-223 Crossref PubMed Scopus (30) Google Scholar , 3 Abuabara A. Cortez A.L. Passeri L.A. et al. Evaluation of different treatments for oroantral/oronasal communications: experience of 112 cases. Int J Oral Maxillofac Surg. 2006; 35: 155-158 Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar Various techniques have been described for repair of the fistula, using buccal fat, palatal rotational flaps, and serratus anterior flaps. 4 Môczair L. A new surgical method of closure of oroantral fistula of odontogenic origin. Ann Stomatol (Roma). 1930; 28: 1087-1088 Google Scholar A new and extremely effective method for addressing larger defects is a vascularised three-layered technique recently described by Darr et al. 5 Darr A. Jolly K. Martin T. et al. Three-layered technique to repair an oroantral fistula using a posterior-pedicled inferior turbinate, buccal fat pad, and buccal mucosal advancement flap. Br J Oral Maxillofac Surg. 2018; 56: 638-639 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Recurrence and chronicity is a major issue, which is mainly due to trauma, sinus disease, or edentulousness. We describe a modification of the three-layered flap for better outcomes for recurrent oroantral fistula.

Management of Oroantral Communication Using Double Layered Closure with Buccal Fat Pad and Buccal Advancement Flap: Prospective Randomized Clinical Study

Introduction: Although many techniques are available for management of oroantral communication, they
 utilize single layer tissue for closure of defect which is composite in nature. There is limited evidence in
 literature regarding efficacy of double layered closure using combination of flaps. This study was designed
 to assess utility of double layer closure of oroantral communication using buccal fat pad and buccal mucosa
 advancement flap.
 Material and Method: Patients with oroantral communication were randomly allocated to two groups;
 group A were treated with two layered closure (buccal fat pad and buccal mucosa) and group B were treated
 with single layer closure (buccal fat pad). Same protocol of perioperative management was used for both
 groups. The postoperative parameters evaluated included success of surgery (complete closure without any
 nasal regurgitation), duration of surgery, pain, swelling and mouth opening.
 Results: Total of 27 patients were divided into group A (n=13) and group B (n=14). The mean size of the
 defect was 28.23 mm in study group and 24.57 mm in the control group. The surgical procedure took more
 time (42.23 minutes) in group A, as compared to group B (26.21 minutes). Post-operative evaluation of pain
 and mouth opening showed no statistically significant between the two groups at 7th and 30th postoperative
 days respectively. However, swelling was relatively more when combination of buccal fat pad and buccal
 advancement flap was used.
 Conclusion: Double layered closure is efficient in management of OAC. No dehiscence of flap was seen in
 study group. Comparatively 3 dehiscence was observed in control group, especially with large size defect.
 The postoperative sequel in both groups was similar.

Reconstruction of microstomia considering their functional status.

Background Microstomia is defined as a condition with a small sized-mouth that results in functional impairment such as difficulty with food intake, pronunciation, and poor oral hygiene and cosmetic problems. Several treatment methods for microstomia have been proposed. None of them are universally applicable. This study aims at analyzing the cases treated at our institution critically reviewing the pertinent literature.Methods The medical records of all microstomia patients treated in our hospital from November 2015 to April 2018 were reviewed retrospectively. Of these, all patients who received surgical treatment for microstomia were included in the study and analyzed for etiology, chief complaint, surgical method, and outcomes. The functional outcomes of mouth opening and intercommissure distance before and after the surgery were evaluated. The cosmetic results were assessed according to the patients’ satisfaction.Results Five patients with microstomia were corrected. Two cases were due to scar contracture after chemical burn, two cases derived from repeated excision of skin cancer, and one patient suffered sequela of Stevens-Johnson syndrome. The following surgical methods were applied: one full-thickness skin graft on the buccal mucosa, three buccal mucosal advancement flaps after triangular excision of the mouth corner, and one local buccal mucosal flap. Mouth opening was increased by 6.0 mm, and the intercommissure distance improved by 7.2 mm on average. Follow-up was 9.6 months (range, 5–14 months). Cosmetic assessment was as follows: two patients found the results excellent, three judged it as good.Conclusion Microstomia has several causes. In order to achieve optimal functional recovery and aesthetic improvement it is important to precisely evaluate the etiologic factors and the severity of the impairment and to carefully choose the appropriate surgical method.

Managing lip large papilloma extirpation defect by arterialized advancement vermilion flap

The close resemblance of squamous papilloma with verrucous carcinoma and the chief etiological factor associated with its development, the human papillomavirus (HPV) raises a doubt about its close association with malignancy. The best way to treat HPV growths is surgical removal and assessment of lesion by histopathology. The defect needs reconstruction with full function and aesthetic outlook. Thirty-seven years old young man with history of tobacco chewing developed slow growing papilloma in upper lip in one year. It was excised fully and the defect was repaired by arterialized lip vermilion mucosal flap based on slightly tortuous labial vessel and so the flap could be elastically stretched even up to fifty percent of lip length and applied successfully. Same patient developed papilloma in lower lip as a separate primary after two years of nonrecurrence of previous operated upper lip papilloma. Lower lip lesion was excised similarly and repaired with same type of vermilion mucosal advancement flap from adjacent part of lower lip defect created. The post-operative period was uneventful and after three years of last operation there is no recurrence in either lip. Vermilion flap which is based on labial artery containing composite tissue comprising of mucosa and portion of orbicularis muscle mainly has been utilized to reconstruct the post excision papilloma lip defect with excellent functional and aesthetic results. There was no microstomia. It is single stage not involving donor site like tongue or cheek mucosa and is good upto half of lower lip defects.

Endorectal Advancement Flap With Muscular Plication in Anovaginal and Anterior Perineal Fistulas.

PurposeEndorectal mucosal advancement flap with muscular plication can ensure complete closure of anovaginal fistulas and preserve continence. The aim of this retrospective study was to show indications might be broadened to include anoperineal fistulas.MethodsThis retrospective study gathered all available data from patients with anovaginal or anterior perineal fistulas who underwent transanal advancement flap repair with muscular plication. A loose seton was passed in the fistula track prior to surgery in all patients. Fistula healing was defined as fistula closure during proctological examination associated with complete resolution of symptoms. ResultsThirty-five patients were included from January 2011 to March 2017. Causes of fistula were various, mostly post-operative (34.3%, n = 12), obstetrical (17.1%, n = 6) and inflammatory (14.3%, n = 5). Success rate was 65.2%. Fistula healing was obtained in 60.0% of patients with Crohn disease in remission. Closure rate was higher in anterior perineal fistulas (89.0%) than in anovaginal fistulas (63.6%) even if it did not reach statistical significance. Slight fecal continence disorders were noted in 2 women (5.7%).ConclusionThis study demonstrates the efficacy of transanal advancement flap repair with muscular plication for anovaginal and anterior perineal fistulas. Similar closure rates and smaller postoperative incontinence rates compared to the classical technique make this surgery an optimal solution whose efficacy appears to be sustainable over time.

Longterm outcome of anal fistula \u2013 A retrospective study

This retrospective observational study analyses the outcomes of patients undergoing surgery for anal fistula at a single centre in order to assess recurrence and re-operation rates after different surgical techniques. During January 2005 and May 2013, all patients with anal fistula were included. Baseline characteristics, details of presentation, fistula anatomy, type of surgery, post-surgical outcomes and follow-up data were collected. The primary endpoints were long-term closure rate and recurrence rate after 2 years. Secondary endpoints were persistent pain, postoperative complications and continence status. A total of 65 patients were included. From a total amount of 93 operations, 65 were fistulotomies, 13 mucosal advancement flaps, 7 anal fistula plugs and 8 cutting-setons. The mean follow up was 80 months. Healing was achieved in 85%. The highest recurrence rate was seen in anal fistula plug with 42%. On the other hand, no recurrence was observed in the cutting-seton procedures. For all included operation no persistent postoperative pain nor incontinence was observed. In conclusion, despite all existing anal fistula operations up to date, the optimal technique with low recurrence rate and assured safety for the anal sphincter is still lacking. Nonetheless, according to our promising results for the cutting-seton technique, this technique, otherwise considered obsolete, should be further evaluated in a prospective study.

Rose-trellis periosteal release in oral mucosal advancement flaps in pigs.

The aims of this study were to find out whether scoring in a rose-trellis pattern improved the stretch of mucoperiosteal flaps more than conventional scoring in the horizontal plane, and to consider its application in the closure of oroantral communications. Sixteen sections of cadaveric porcine buccal mucoperiosteum were removed from the molar region of the maxilla and mandible. A three-sided flap was raised in the subperiosteal plane, excised, and pinned to a cork board with the periosteal side facing upwards. Eight samples were scored in the horizontal plane (control) using lines perpendicular to the line of simulated advancement, and eight in a rose-trellis or criss-cross pattern. Scoring using a rose-trellis pattern yielded a mean increase in stretch of 24.3% (p=0.0003) when compared with the conventional method. Buccal advancement flaps are widely used to close oroantral communications, and scoring of the mucoperiosteum facilitates the stretching of the tissue over the defect. To be successful, defects should be fully closed to prevent contamination, and closure should be tension-free. In this study, scoring in a rose-trellis pattern increased the stretch of the tissue sample more than scoring in the horizontal plane. The rose-trellis technique therefore could aid the effective closure of oroantral communications.

Management of Postpartum Rectovestibular Fistula with Vaginal and Rectal Mucosal Advancement Flap

Women with acquired rectovestibular fistula following obstetric injuries were treated with excision of fistulous tract and reconstruction by a different technique. Four women with acquired rectovestibular fistula underwent excision of fistulous tract and the resulting defect was repaired. The resulting muscular defect was closed, posterior vaginal wall mobilised and sutured to cover the vestibular aspect of the fistula, and the anterior rectal wall was mobilised and sutured to cover the rectal aspect of the fistula. The combined advancement of rectal and vaginal mucosa provides sound protection to the sutured muscle defect in the fistulous area both on the vestibular and rectal sides, thus preventing recurrence. In spite of fewer number of patients, follow-up for five years have shown no recurrence following this novel procedure in women with postpartum H-type of rectovestibular fistula. Though rectal mucosal advancement has been well documented, the addition of vaginal mucosal advancement is emphasised to prevent recurrence.

Rectal advancement flaps for the treatment of transphincteric perianal fistulas: a three-dimensional endoanal ultrasound and quality of life assessment.

This study quantifies the damage to the internal anal sphincter (IAS) after a rectal mucosal advancement flap for a high transphincteric fistula in 16 patients using 3D-endoanal ultrasound. This was correlated with postoperative incontinence and quality of life scores. The median length of involved IAS preoperatively was 50 % (20-100) and 93.72 % for EAS (47.4-100 %). IAS division did not influence continence (p > 0.05). Continence deteriorated between the pre-, postoperative (p = 0.014) and six-month follow-up (p = 0.005), with no significant differences after one year (p > 0.05). The FIQOL score and SF-36 deteriorated initially, with recovery in all domains except for mental health after one year. Three fistulas recurred (18.75 %).

Closure of septal perforation using unilateral mucosal advancement flaps

Closure of septal perforation using unilateral mucosal advancement flaps

Minimally invasive treatment of mid-low rectovaginal fistula: a transanal endoscopic surgery study.

Treatment of rectovaginal fistulas (RVFs) is extremely difficult. No standard surgical procedure is accepted worldwide. The aim of this article was to evaluate a minimally invasive procedure for the repair of mid-low rectovaginal fistula. This is a retrospective review of 17 patients who underwent minimally invasive surgery for the repair of mid-low rectovaginal fistulas (located in the lower or middle one-third of the vaginal wall) at our center between August 2016 and October 2018. The anal approach was adopted for 12 patients: 6 patients were treated directly by rectal mucosal advancement flap (RMAF) with transanal endoscopic surgery (TES), while the other 6 patients underwent initial TES exploration followed by RMAF procedure under direct vision. The vaginal approach was adopted for 5 patients: 3 patients were treated under TES directly and the other 2 were treated under direct vision after initial TES exploration. A total of 9 (52.94%) patients received diverting ileostomy-5 anal approach patients and 4 vaginal approach patients. Median age of the patients was 46years (range 10-76years), and median BMI was 21.9 (range 17.9-28.1). Median operative time was 75min (range 60-120min), and median duration of postoperative hospital stay was 8days (range 6-15days). Recurrence was seen in 3/12 anal approach patients vs. 0/5 vaginal approach patients. Both the median preoperative and the median postoperative Wexner score were 0 (range 0-2). The median follow-up time was 8months (range 2-24). No severe complications occurred in any patient. The TES procedure for the treatment of mid-low rectovaginal fistulas avoids any incision of the abdomen and perineal area and appears to be a safe and feasible procedure. This minimally invasive technique is still evolving and is likely to gain wide acceptance in the near future.

Risk Factors for Recurrence after anal fistula surgery: A meta-analysis.

Despite a burgeoning literature during the last two decades regarding perioperative risk management of anal fistula, little is known about its risk factors that influence postoperative recurrence. We performed a meta-analysis to summarize and assess the credibility of evidence of potential risk factors for anal fistula recurrence (AFR) after surgery. Pubmed and EMBASE without language restriction were searched from inception to April 2018 that reported risk factors which predisposed recurrence after anal fistula surgery. We excluded studies that involved patients with anal fistula associated with Crohn's disease. MOOSE guidelines were followed when this meta-analysis was performed. We used random-effects models to pool relative risks (RRs) with 95% confidence intervals (CIs). Evidence from observational studies was graded into high-quality (Class I), moderate-quality (Class II/III) and low-quality (Class IV) based on Egger's P value, total sample size and between-study heterogeneity. Of 3514 citations screened, 20 unique observational studies comprising 6168 patients were involved in data synthesis. High-quality evidence showed that AFR was associated with high transsphincteric fistula (RR, 4.77; 95% CI, 3.83 to 5.95), internal opening unidentified (RR, 8.54; 95% CI, 5.29 to 13.80), and horseshoe extensions (RR, 1.92; 95% CI, 1.43 to 2.59). Moderate-quality evidence suggested an association with prior anal surgery (RR, 1.52; 95% CI, 1.04 to 2.23), seton placement surgery (RR, 2.97; 95% CI, 1.10 to 8.06), and multiple fistula tract (RR, 4.77; 95% CI, 1.46 to 15.51). High-quality evidence demonstrated no significant association with gender or smoking; moderate-quality evidence also suggested no association with age, tertiary referral, alcohol use, diabetes mellitus, obesity, preoperative seton drainage, high internal opening, postoperative drainage, mucosal advancement flap surgery, supralevator extensions, location or type of anal fistula. Several patient, surgery and fistula-related factors are significantly associated with postoperative AFR. These findings strengthen clinical awareness of early warning to identify patients with high-risk disease recurrence for AFR.