Rectal Advancement Flap Research Articles

Closing the internal opening with a rectal advancement flap increases the efficacy of mesenchymal stem cell injection for complex Crohn's disease anal fistulas.

The efficacy of injections of mesenchymal stem cells (MSC) for anal fistula treatment may be impaired by the persistence of stools passing into the fistula, causing bacterial contamination and a local inflammatory reaction. We aimed to compare remission rates between patients treated by MSC injection with simple sutures and those treated with a rectal advancement flap. This single-center prospective study compared the first patients who underwent internal opening closure with sutures with the subsequent patients treated with a flap. Complete clinical remission was defined as complete closure of the external opening(s) without pain or discharge, and complete radiological remission was defined as a Magnifi-CD score of 0. We compared the first 42 patients who had sutures with the 20 subsequent patients who had an advancement flap. The median follow-up was 15.5 [8.8-24.9]months. The cumulative incidence of complete clinical response at M12 was 53.8% [38.1-69.6%] in the suture group versus 93.3% [77.4-100.0] in the flap group (p < 0.001). The Magnifi-CD score was 0 for 41.7% [25.5-59.2%]) of patients treated with sutures versus 72.7% [39.0-63.9%]) of patients treated with a flap (p=0.093). Anal incontinence score did not differ between the two groups. Practicing an advancement flap was the only significant factor associated with complete clinical remission over time (adjusted HR [95% CI] of 2.6 [1.4-4.9], p = 0.003). Complete clinical remission rates following MSC injection are significantly higher after closure of the internal opening with a rectal flap than after closure with sutures, without consequences on anal continence.

P933 Closing the internal opening with a rectal advancement flap increases the effectiveness of mesenchymal stem cell (MSC) injection in the treatment of complex Crohn's disease anal fistulas

Abstract Background The injection of MSCs into complex anoperineal fistulas of Crohn's disease gives a combined clinical and radiological remission of between 35 and 50% at 12 months. In our department, surgical closure is now done by rectal advancement flap (and no longer with simple stitches) in order to minimize the passage of stools and contamination of the fistula tract. The aim of this study was to compare the remission rate and the quality of life between patients treated with MSC injection using simple stitches versus a rectal flap to close the internal opening. Methods This single-center prospective study included all our consecutive patients who had a MSC injection. The first patients of the series who had closure of the internal opening(s) with stitches (2020- 2022) were compared with those who had a flap (2022-2023). Complete clinical remission was defined by complete closure of the external opening(s) without pain or discharge, and complete radiological remission by a Magnifi-CD score equal to 0 (Hindryckx P, et al. Gastroenterology 2019). Quality of Life was assessed by the Crohn's Anal Fistula Quality of Life scale (CAF-QoL) (Adegbola SO, et al. Gut 2021). Results We included 68 patients (50% women, mean age: 38 ± 13.8 years). The first 42 had stitches and the following 20 had an advancement flap (6 patients had no procedure due to an anal stenosis). The median follow-up was 12 months [6-24]. The overall complete clinical remission was 66.7% at M12: 51.1% [35.5-66.8] in the "stitches" group versus 87.5% [69.7-100.0] in the "flap" group (p = 0.005) (Figure). The difference was noticed early from M1. The mean overall Magnifi-CD MRI score decreased from 15.5 ± 4.7 to 6.5 ± 7.1 at M12 (p &amp;lt; 0.001) with no difference between the 2 groups. However, more patients in the flap group had a Magnifi-CD score of 0: 62.5% versus 38.2%. The CAF-QoL quality of life score improved from 51.3 ± 24.7 to 21.2 ± 20.8 at M12 (p &amp;lt; 0.001) with no significant difference between the 2 groups. The duration of the procedure was longer on average by 19 ± 7 minutes in the "flap" group. There was no difference in the anal incontinence score between the 2 groups. In logistic regression, the advancement flap was significantly associated with complete clinical remission (p = 0.007, HR (95% CI): 2.3 [1.3-4.3]). Conclusion Closing the internal opening with a rectal advancement flap improves the effectiveness of MSC injections with a complete clinical and radiological remission rate of 87.5% and 62.5% respectively, without consequences on anal continence.

Role of Laser Ablation of Fistula Tract in High Perianal Fistula

Abstract Background Complex anal fistula has been a hot topic in clinic. Many surgical techniques have been described for the treatment of such anal fistula, including the use of seton, fibrin glue, collagen plugs, rectal advancement flaps, fistulotomy with sphincter repair, and rerouting the fistula tract. However, the results have been variable, and no one procedure is superior to the others absolutely. It is worth our concern that the goal of any treatment procedure is to obliterate the tract and to have low recurrence rates while maintaining full continence. A fistulotomy lays open the fistulous tract, thus leaving smaller unepithelized wounds, which hastens the wound healing. Until now, fistulotomy is still the most widely used. But, the high cure rate is limited by the fact that laying open a transsphincteric fistula tract and cutting both the internal and the external sphincter has the risk of fecal incontinence ranging up to 40%. Aim of the Work To assess and evaluate the efficacy and safety of LASER ablation of high perianal fistula. Patients and Methods This study is a randomized prospective study which will be conducted at Ain Shams University hospitals recruiting (20) patients and will be operated upon between January 2021 and July 2021 with minimal follow up to 3 months postoperatively. Results From these studies, it emerges that this procedure has some advantages. It doesn’t affect continence, administers controlled hyperthermic effect to the tissues, has a short learning-curve and reduces postoperative hospital stay as compared to endorectal advancement flap or LIFT. However, it has also some drawbacks. It is a blind procedure, as it’s not possible a direct visualization of the fistula tract or any secondary tracts and this may lead to recurrence. It requires expensive equipment, particularly if compared to other sphincter-saving techniques. Conclusion LASER ablation is a technique that has a promising results regarding complex perianal fistula preserving anal continence and short healing period and low recurrence rate as regarding classic and other techniques.

Compartive Study between Conventional Laying-Open Technique with Sphincter Repair and Ligation of Intersphincteric Fistula Tract (LIFT) in Treatment of High Trans-Sphincteric Perianal Fistula

Abstract Background Complex anal fistula has been a hot topic in clinic. Many surgical techniques have been described for the treatment of such anal fistula, including the use of seton, fibrin glue, collagen plugs, rectal advancement flaps, fistulotomy with sphincter repair, and rerouting the fistula tract. However, the results have been variable, and no one procedure is superior to the others absolutely. It is worth our concern that the goal of any treatment procedure is to obliterate the tract and to have low recurrence rates while maintaining full continence. A fistulotomy lays open the fistulous tract, thus leaving smaller unepithelized wounds, which hastens the wound healing. Until now, fistulotomy is still the most widely used. But, the high cure rate is limited by the fact that laying open a transsphincteric fistula tract and cutting both the internal and the external sphincter has the risk of fecal incontinence ranging up to 40%. Objective To retrospectively evaluate the success rate, the recurrence and incontinence when using the Conventional laying-open and sphincter Repair technique in comparison to Ligation of Intersphincteric Fistula Tract (LIFT) for treating high trans-shpincteric perianal fistula. Patients and Methods This was a cohort retrospective, comparative study that was conducted on cases of fistula in the anus, who were subjected to surgery in Ain Shams University Hospitals and Ain shams specialized hospitals in the period from October 2021 to March 2022 (at least 30 cases) to evaluate the success rate, the recurrence rate, and incontinence rate when using the conventional laying open with sphincter repair technique compared to ligation of inter-sphincteric fistula tract (LIFT) For High trans-sphincteric perianal fistula. Results Regarding Relation of recurrence with demographic data of the studied patients, de novo/recurrent, Wexner score before and after operation and complications. that there was no statistically significant relation found recurrence with demographic data of the studied patients, de novo/recurrent, Wexner score before and after operation while there was statistically significant relation found with complications. Conclusion LIFT procedure is an effective and preferred sphincter-saving technique for fistula-inano with shorter healing time and lower incidence of postoperative anal incontinence, but have higher incidence of recurrence as compared to conventional layopen with sphincter repair which have a lower incidence of recurrence but have a relatively longer Healing time and higher incidence of postoperative anal incontinence. Both techniques are effective, have post operative good results and safe in treatment of high transsphincteric perianal fistula but Further research work is still warranted to confirm the long term outcome of these 2 techniques with a larger sample size and a longer follow up period. To know which technique is superior over the other.

What are the outcomes in patients referred to a tertiary referral centre for Crohn's rectovaginal fistula surgery?

Rectovaginal fistulas in patients with Crohn's disease are challenging to manage, and surgical treatment remains the best option for achieving permanent closure of the fistula. Biologicals are now used routinely for patients with Crohn's disease. The aim of this study was to investigate the surgical procedures used by us to treat rectovaginal fistula in patients with Crohn's disease in the era of biologicals. Patients with Crohn's disease who underwent surgery for a rectovaginal fistula between 2010 and 2020 were included in this retrospective study and were identified from a prospectively maintained institutional database. Collected variables included demographics, perioperative and operative variables and data regarding medications used. Success of the procedure was defined as no symptoms at least 6 months after definitive repair and/or stoma closure. Twenty patients (out of 80 referred for evaluation) underwent surgery with intent to close the fistula and had at least 6 months of follow-up. Mean age was 44 ± 12 years with a median follow-up duration of 33 months (range 6-130 months). Forty per cent of the patients had a history of at least two surgeries to close the fistula. The overall healing rate was 70% (14/20). The most performed procedure was a transanal rectal advancement flap (7/20), with a success rate of 85%. Rectovaginal fistula in Crohn's disease is difficult to cure; according to our results almost half of these patients have multiple surgeries due to recurrence. Multiple procedures may be offered for this challenging problem in motivated patients. Perioperative diversion should be strongly considered.

Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Repair of Post-partum Rectovaginal Fistulas-A Single-Center Experience.

Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF. A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal. Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure. Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate.

Surgery of Simple and Complex Anal Fistulae in Adults: A Review of the Literature for Optimal Surgical Outcomes.

Anal fistulas are common anorectal conditions, and surgery is the primary treatment option. In the last 20 years of literature, there exist a large number of surgical procedures, especially for the treatment of complex anal fistulas, as they present more recurrences and continence problems than simple anal fistulas. To date, there are no guidelines for choosing the best technique. We conducted a recent literature review, mainly the last 20 years, based on the PubMed and Google Scholar medical databases, with the goal of identifying the surgical procedures with the highest success rates, lowest recurrence rates, and best safety profiles. Clinical trials, retrospective studies, review articles, comparative studies, recent systematic reviews, and meta-analyses for various surgical techniques, as well as the latest guidelines of the American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, and the German S3 guidelines on simple and complex fistulas were reviewed. According to the literature, there is no recommendation for the optimal surgical technique. The etiology, complexity, and many other factors affect the outcome. In simple intersphincteric anal fistulas, fistulotomy is the procedure of choice. In simple low transsphincteric fistulas, the patient's selection is crucial in order to perform a safe fistulotomy or another sphincter-saving technique. The healing rate in simple anal fistulas is higher than 95% with low recurrence and without significant postoperative complications. In complex anal fistulas, only sphincter-saving techniques should be used; the optimal outcomes are obtained by the ligation of the intersphincteric fistulous tract (LIFT) and rectal advancement flaps. Those techniques assure high healing rates of 60-90%. The novel technique of the transanal opening of the intersphincteric space (TROPIS) is under evaluation. The novel sphincter-saving techniques of fistula laser closure (FiLac) and video-assisted anal fistula treatment (VAAFT) are safe, with reported healing rates ranging from 65% to 90%. Surgeons should be familiar with all sphincter-saving techniques in order to face the variability of the fistulas-in-ano. Currently, there is no universally superior technique that can treat all fistulas.

Advancing standard techniques for treatment of perianal fistula; when tissue engineering meets seton

Tissue engineering is a promising field for treating various diseases using tissue-like structures generated through biomaterials, scaffolds, nanoparticles, biomolecules, and stem cells. This advanced method is considered one of the next-generation therapeutic techniques that may solve the therapeutic challenges in treating perianal fistula based on seton therapy. Remarkable advances in stem cell biology, genetics, biomaterials, fabrication technologies, and nanotechnology have provided the opportunity to implement this multidisciplinary approach to repair damaged tissue in the seton-based fistula treatment. In addition, tissue engineering provides us with nanostructured biomaterials to fabricate setons that can act as scaffolds, with modified mechanical and biological properties such as antibacterial and anti-inflammatory. This review focuses on the applications, advantages, and future perspectives of tissue engineering to enhance the seton placement techniques and present a novel therapeutic solution to treat perianal fistula. In addition, in vivo and in vitro studies about implementing tissue engineering in the treatment of perianal fistula are reported in this study. Also, it summarizes the surgical procedures for the treatment of fistula, including Ligation of the Intersphincteric Fistula Tract (LIFT), Fistula Laser Closure (FiLaC™), Over-The-Scope Clip System (OTSC), Video-assisted anal fistula treatment (VAAFT), Anal fistula plug (AFP), and Rectal advancement flap (RAF). Furthermore, the applications and properties of different setons including, cutting setons (Penrose drains, rubber band, polypropylene, and silk), non-cutting setons (loose, knot-free, Comfort, and Super Seton®), and chemical setons (Ksharasutra) are described. In the end, we present the challenges and future trends of implementing tissue engineering technology in the seton-based therapy for the treatment of perianal fistula. The applications of tissue engineering in seton-based fistula therapy. The scaffolds with controllable mechanical properties and degradation rate can have antibacterial, anti-inflammatory, and drug-releasing properties. Besides, the scaffolds can be incorporated or covered with stem cells to regenerate damaged tissues in the perianal fistula site.

Healing of rectal advancement flaps for anal fistulas in patients with and without Crohn\u2019s disease: a retrospective cohort analysis

BackgroundSurgical closure of anal fistulas with rectal advancement flaps is an established standard method, but it has a high degree of healing failure in some cases. The aim of this study was to identify risk factors for anal fistula healing failure after advancement flap placement between patients with cryptoglandular fistulas and patients with Crohn’s disease (CD).MethodsFrom January 2010 to October 2020, 155 rectal advancement flaps (CD patients = 55, non-CD patients = 100) were performed. Patients were entered into a prospective database, and healing rates were retrospectively analysed.ResultsThe median follow-up period was 189 days (95% CI: 109–269). The overall complication rate was 5.8%. The total healing rate for all rectal advancement flaps was 56%. CD patients were younger (33 vs. 43 years, p < 0.001), more often female (76% vs. 30%, p < 0.001), were administered more immunosuppressant medication (65% vs. 5%, p < 0.001), and had more rectovaginal fistulas (29% vs. 8%, p = 0.001) and more protective stomas (49% vs. 2%, p < 0.001) than patients without CD. However, no difference in healing rate was noted between patients with or without CD (47% vs. 60%, p = 0.088).ConclusionsPatients with anal fistulas with and without Crohn’s disease exhibit the same healing rate. Although patients with CD display different patient-specific characteristics, no independent factors for the occurrence of anal fistula healing failure could be determined.Trial registration Not applicable due to the retrospective study design.

Surgery for anal fistulae: state of the art.

Anal fistulae (AF) are considered a challenge for colorectal surgeons, as they recur if not properly operated. Being a septic disease, they are correlated with immunodeficiency and surgery may be followed by anal incontinence (AI). The aim of this paper is to suggest a state-of-the-art treatment of AF. Pathogenesis, classification, diagnostic tools, intraoperative assessment, and surgeries proposed for AF have been reviewed, together with the results following conventional surgery and innovations aimed at sphincters' preservation. Stress causes immunodepression and favors anal sepsis, and heavy smoking facilitates AF recurrences. Evacuation fistulography, MRI, and transanal ultrasound may help the diagnosis. Fistulotomy allows high cure rate, up to 96.4%, but may cause up to 64% of AI in transsphincteric AF. Fistulectomy with rectal advancement flap is effective in 80% of these cases and avoids AI. Other options are either suturing of AF internal orifice or positioning a cutting seton. Ligation of intersphincteric fistula track (LIFT) is a costless alternative carrying a success of 57-99% with 0-23% AI. Costly innovations, i.e., autologous stem cells, porcine derma sheet (Permacol), video-assisted fistula excision (VAAFT), porcine matrix (PLUG), and laser closure (FiLaC), minimize AI, but may carry AF recurrence. Their grades of recommendation range between 2B and 2C in the Guidelines of the Italian Society of Colorectal Surgery. Postoperative incontinence in transsphincteric AF may be minimized by both costless and costly sphincter-saving procedures, the latter carrying higher recurrence rate. The success of surgery may be increased by a different lifestyle.

COMPARATIVE STUDY BETWEEN STAGED RE-ROUTING AND RECTAL ADVANCEMENT FLAP WITH CURETTAGE OF FISTULA TRACT IN TREATMENT OF HORSE SHOE PERIANAL FISTULA

Background: Complex anal fistula has been a hot topic in clinic. Many surgical techniques have been described for the treatment of such anal fistula, including the use of seton, fibrin glue, collagen plugs, rectal advancement flaps, fistulotomy with sphincter repair, and rerouting the fistula tract. However, the results have been variable, and no one procedure is superior to the others absolutely. It is worth our concern that the goal of any treatment procedure is to obliterate the tract and to have low recurrence rates while maintaining full continence. Comparison was made between the two procedures (re-routing and rectal advancement flap) to stand on the superiority of each one over the other. We compared data including: Healing time, post operative bleeding and infection, recurrence rates and continence. Patients and Methods: The study was conducted over 40 patients with high trans-sphincteric fistulas, randomly divided into 2 equal groups, who underwent Rerouting of the tract in one group and rectal advancement flap in the other group.Results: Rerouting technique and rectal advancement flap have nearly similar incidence of post operative complications and continence but rectal advancement flap is associated with short healing period and a high recurrence rate as compared to re-routing technique.Conclusion: In patients with high trans-sphincteric anal fistulas, rectal advancement falp has a short healing period but a high recurrence rate which was statistically insignificant.

Redo Repair of a Recurrent Rectovaginal Fistula With Rectal Advancement Flap

Redo Repair of a Recurrent Rectovaginal Fistula With Rectal Advancement Flap

Video-Assisted Anal Fistula Treatment for Treatment of Complex Cryptoglandular Anal Fistulas with 2 Years Follow-Up Period: Our Experience.

Aim: The aim of this prospective, nonrandomized, observational study was to present our results in operative treatment of complex anal fistulas using video-assisted anal fistula treatment (VAAFT) procedure with a curative intent in 2 years follow-up period. Materials and Methods: Between March 2016 and March 2018, 73 patients underwent the VAAFT procedure. Postoperative follow-up was 2 years, up to March 2020. Only patients with complex cryptoglandular anal fistulas were included. All patients were referred for magnetic resonance imaging of the pelvis. Fecal incontinence severity index score was used to assess any continence disturbance prior operation and postoperatively. Result: Primary healing occurred in 52 cases (71.23%) after first operation. From 21 patients who had recurrence or who had persisting disease, 16 patients accepted reoperation with second VAAFT procedure and additionally 10 patients achieved healing. From a total number of 73 patients who were included in study healing ultimately occurred in 62 cases (84.93%). In the first operation internal opening was identified in 47 cases (64.38%) and was closed with mattress suture, rectal advancement flap or ligation of intersphincteric fistula tract technique depending on its extent and type of fistula. Median primary healing rate was 6 weeks. There were no serious intra- or postoperative complications. None of the patients reported any type of continence disturbance. Discussion: VAAFT has been shown to offer good rates of healing, low morbidities, possibilities of multiple attempts in case of first failure and this series adds to the literature.

Manejo de la fístula anorrectal compleja. LIFT, colgajo de avance y otras técnicas.

Las fístulas anorrectales complejas son un desafío para el coloproctólogo. Son una patología frecuente que afecta la calidad de vida de los pacientes. La patogénesis aún no esta clara, estarían involucradas citoquinas y el proceso de transición de epitelio a mesénquima. El gold estandar para su estudio es la resonancia nuclear magnética, su uso por si mismo disminuye la recurrencia. El objetivo del tratamiento es lograr la curación sin afectar la función del esfínter evitando las recidivas. Existen múltiples técnicas, siendo la de mayor aceptación la ligadura interesfinteriana del trayecto fistuloso, con tasa de curación sobre el 70%, con mínimo impacto en continencia. Esta revisión incluye otras técnicas como el colgajo endorrectal de avance, uso de sellante, Permacol, células madres, Anal fistula plug, Video asisted anal fistula treatment, Over the scope clip y Fístula laser closure.

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.

P199 Outcomes of Crohn’s rectovaginal fistulae in a specialist centre

Abstract Background Rectovaginal fistula (RVF) is a devastating complication of Crohn’s disease (CD). Despite advances in medical and surgical treatment, management of CD RVF remains challenging. Surgery is the principal treatment with adjunctive medical therapy. This study tracks patients from initial fistula presentation through their treatment pathways. Methods We reviewed our retrospective RVF database (2009–2019). Patients were captured through imaging and surgical coding. Outcomes included patient satisfaction, fistula closure and stoma reversal. Results We identified 66 patients with CD RVF from our database of 327 RVF patients, with a median age of 40 years and mean follow up of 6.3 years. Cross-sectional analysis of patients’ initial symptoms, management and outcomes identified three groups: 1-quiescent luminal disease, with minimal fistula symptoms; 2-quiescent luminal disease, but moderate fistula symptoms (suitable for RVF repair); 3-poorly controlled luminal disease and active fistula, requiring medical control and/or defunctioning before RVF repair. Thirty-one patients were identified in group 1 (‘minimal symptoms’). The median age was 37 years and most were on Infliximab (32%) or combination therapy (45%). Patients reported a negative impact on the quality of life (QoL) (39%), such as sex avoidance and psychosocial impairment. Some patients later required defunctioning (22%) or proctectomy (13%). Fistula symptoms improved in 16% following medical treatment alone. One patient developed a mucinous adenocarcinoma. Nine patients were identified in group 2 (‘immediately suitable for repair’). The median age was 44 years. A low QoL was reported in 44%. Reparative procedures included rectal advancement flap and omentoplasty. Two patients were defunctioned. Fistula closure was seen in 44% after medical and surgical treatment. Twenty-six patients presented in group 3 (‘poorly controlled luminal disease and active fistula’) and 17 patients joined this group after symptom deterioration (15 from group 1 and 2 from group 2). The median age was 45 years. All patients were on biologics/combination therapy and defunctioned. Some 30% underwent proctectomy. Some patients declined stoma reversal (7%) and proctectomy (12%). Markedly poor QoL was reported in 35% of patients. Medical escalation resulted in fistula closure in 14% of patients. Conclusion Complex RVF with poorly controlled disease requires faecal diversion/proctectomy and optimal medical therapy. Well-timed reparative surgery in a selected group yields reasonable outcomes. Management is dependent on factors such as the extent of CD, fistula symptoms, response to medical treatment, suitability for local repair and patient choice.

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 %).

Rectal Flap Experience in High Transsphincteric Cryptoglandular Anal Fistula

Aim: Despite many treatment modalities, anal fistula disease remains an important problem. High recurrence rates have been reported in the surgical treatment of complicated anal fistulas. We hereby present complicated anal fistula patients treated with rectal advancement flaps. Methods: Patients who underwent rectal advancement flap surgery by a single surgeon between 2009 and 2019 were analyzed in this retrospective cohort study. Demographic data, number of previous operations, recurrence rate and complications were recorded. Results: Twenty patients (15 males and 5 females) underwent surgery with the rectal advancement flap technique. Nine patients had more than one previous operation. Seton, partial fistulectomy and curettage were the most performed operative techniques in their previous surgeries. The mean follow-up period was 31 months (3-74). Among 13 patients with follow up periods longer than 12 months, 3 patients had recurrences (23%), all of which had been previously operated twice or more. Conclusion: Although rectal advancement flap is not the first choice in the treatment of complicated and high transsphincteric fistulas, it still maintains its importance. Experienced surgeons prefer this method due to its sphincter-sparing nature. In our study we detected a recurrence rate of 23% and incontinence rate of 5%, which was thought to be related to previous surgeries.

Radiofrequency thermocoagulation for high transphincteric fistulae, Merlini l'Héritier et al.

Obliteration of the internal opening has long been held as the key resolution of high transsphincteric fistulae. This month's Editor's Choice by Merlini l'Héritier et al. evaluated ablation of the tract by applying radiofrequency thermocoagulation 1. They used a control group, selected from a prospective database consisting of patients who underwent occlusion of the fistula tract by a rectal advancement flap, paired-matched for sex, age and the presence of Crohn's disease. The healing rate was only 26% at 5 months after radiofrequency thermocoagulation, vs 68% after flap repair, and dropped further to 10% after 21 months. These findings suggest that obliteration of the fistula tract is not enough to accomplish healing of perianal fistulae in most cases. The authors must be congratulated on publishing these findings. Negative findings provide much needed feedback on the effectiveness of treatment after introducing a new technique or pursuing new indications for a known technique. Radiofrequency thermocoagulation has become common practice as the primary treatment of varicose veins. Recently, new indications for the radiofrequency technique have been defined. For example, obliteration of the sinus in simple pilonidal disease with radiofrequency has been shown to be highly successful 2. We now know that pilonidal disease is caused by loose hairs entering the pits in the intergluteal cleft by their root ends, where a foreign body reaction creates the pilonidal sinus. Consequently, it is understandable that after removing the hairs from the pilonidal cavity, obliteration of the pits by thermocoagulation in order to avoid future potential ports of hair re-entry is a sound treatment principle. The pathophysiology of cryptoglandular and Crohn's fistulae has not been conclusively established. Crohn's disease is thought to be caused by a failure of the intestinal mucosal immune system to tolerate commensal bacteria. The highest healing rates in the featured study were achieved in patients with Crohn's disease (overall success 64 percent) 1. All these patients were on anti-tumour necrosis factor alpha therapy. There is now growing evidence that in patients with Crohn's fistulae, it is essential to combine surgery with biologic agents 2, 3. When managing Crohn's fistulae, combining a surgical procedure, which prevents entry of bacteria to the fistula, with immunotherapy seems to be the logical approach. The overall healing rate in patients with cryptoglandular fistulae was only 41% at 5 months follow-up 1. The persistent inflammation in the anal crypt is nowadays believed to occur as a result of a defective local immune system. Hence, before introduction of new surgical techniques, a better understanding of what process drives this ongoing perianal sepsis is recommended.

FISTULOTOMY FOR THE SURGICAL TREATMENT OF PERIANAL FISTULA OF CRYPTOGLANDULAR ORIGIN

Perianal fistula usually results from a non-specific infection of the cryptic glands located at the anal dentate line. Identification of the exact course of a perianal fistula and the extent of anal sphincteric complex involvement are of paramount importance, in order to design the therapeutic and interventional approach and achieve the best results without impairment of the anorectal function. Several interventional methods are in use for the surgical treatment of CPF, including fistulotomy, insertion of cutting “seton”, core fistulectomy, ligation of the intersphincteric fistulous track (LIFT), rectal advancement flap, injection of fibrin glue at the fistulous track, insertion of fistulous plug, and obliteration of the fistulous track with the use of Laser. In clinical practice a combination of the aforementioned methods can be used, in particular for the complex-high or recurrent fistulae.