Rectal Advancement Flap Research Articles

A comparative study on the effectiveness of rectal advancement flap and seton placement surgeries in patients with anal fistula on the rate of recurrence, incontinence and infection.

Introduction:Due to the high prevalence of anal fistulas and the recurrence of the disease following surgery, different methods have been suggested for appropriate treatment of this disease. In this study, the effects of rectal advancement flap surgery and seton placement on the recurrence rate, incontinence and wound infection were compared.Methods:In this interventional, prospective and quasi-experimental study, 45 patients with anal fistulas including 28 males and 17 females were studied for 2 years (2015-2017). Patients were divided into two groups and mucosal advancement flap and seton placement techniques were used for each of them. Descriptive analysis of data was performed by SPSS software.Results:24 patients (54%) had seton placement surgery and 21 patients (46%) underwent rectal advancement flap surgery. Recurrence was significantly higher in patients who underwent seton placement surgery than the group that underwent rectal advancement flap surgery. Twelve patients (57%) who underwent rectal advancement flap surgery showed improvement in sphincter tone while 11 patients (45%) showed improvements with seton placement.Conclusion:The overall results of this study showed that rectal advancement flap surgery reduces recurrence and wound infection more significantly than seton placement in patients with anal fistula.

Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences.

PurposeRectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures.MethodsBetween 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted.ResultsThe median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058).ConclusionRadiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.

Advancement flap procedure in Crohn and non-Crohn perineal fistulas: a simple surgical approach.

Rectal flap advancement is still a part of therapeutic management of anal fistulas. Data on the outcome of rectal flap advancement in patients with Crohn's disease (CD) is scarce. Our objective was to ascertain rates of failure of rectal flap advancement and to determine predictive factors for failure, with a special focus on CD METHOD: The patients' details, the characteristics of the fistula and the main clinical and therapeutic events were prospectively assessed among patients who underwent rectal flap advancement. All patients had a partial-thickness rectal flap advancement. Failure of primary rectal flap advancement was defined as the occurrence of at least one of the following: abscess, discharge, visible external opening, further drainage procedure. The rates of failure of rectal flap and the predictive factors of failure were assessed. Eighty-seven patients (34 patients with CD) were included. The median (interquartile range) follow-up was 13.3 (3.8-38.1) months. The cumulative failure rates were 15.9% (10.3-23.6), 23.0% (16.0-31.8), 31.6% (22.9-41.8) and 41.3% (30.5-53.0) at 3, 6, 12 and 24months respectively. These data were comparable in Crohn's patients. Those with a supralevator fistula [hazard ratio2.53 (1.01-7.71), P=0.0476] and patients who had fewer than two fistula drainages before rectal flap [hazard ratio3.19 (1.40-8.23), P=0.005] were associated with higher rectal flap failure rates. In CD patients, the absence of biological therapy at referral was predictive of failure. Rectal flap advancement is a satisfactory option for the therapeutic management of anal fistula, including CD populations. Fistula drainage is needed before performing this surgical technique.

RECTAL ADVANCEMENT FLAP TREATMENT COMPARED WITH SETON FOR HIGH TRANSSPHINCTERIC PERIANAL FISTULA

Treatment of anal fistula is a balance between maximizing the chances of successful healing and avoidingcomplications particularly incontinence from division of the anal sphincters. Many surgical procedures have been usedin the treatment of anal fistula, with varying success. Endorectal advancement flap can be a useful tool for the surgeonfaced with an anal fistula. This study aims to compare outcomes for rectal flap advancement in comparison to setonplacement in treating high transsphincteric perianal fistula.

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement. The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence. A retrospective review was performed at 3 university-affiliated teaching hospitals. All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded. The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed. Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics. This study was limited by its retrospective design. Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

What happens after a failed LIFT for anal fistula?

BackgroundLigation of the intersphincteric fistula tract (LIFT) was developed to treat transsphincteric anal fistulas. The aftermath of a failed LIFT has not been well documented. MethodsRetrospective chart review of LIFT procedure for transsphincteric anal fistula between March 2012 and September 2016. Results53 patients with LIFT procedure were identified, 20 (37.7%) had persistent fistula with median followup of 4 months. Following LIFT, recurrence of fistula was transsphincteric (75%) or intersphincteric (25%) (p = NS). Persistent transsphincteric fistulas after LIFT were treated with seton (71.4%) followed by advancement flap (20%) or fistulotomy (50%). Of the recurrent intersphincteric fistulas, 50% underwent seton placement followed by fistulotomy, or advancement flap. Of the patients who underwent surgery after failed LIFT, 50% have had resolution of the fistula; 31.7% are still undergoing treatment. ConclusionPatients who underwent surgery after failed LIFT had 50% healing with placement of seton followed by fistulotomy or rectal advancement flap.

Anoperineal lesions in Crohn's disease: French recommendations for clinical practice.

Anoperineal lesion (APL) occurrence is a significant event in the evolution of Crohn's disease (CD). Management should involve a multidisciplinary approach combining the knowledge of the gastroenterologist, the colorectal surgeon and the radiologist who have appropriate experience in this area. Given the low level of evidence of available medical and surgical strategies, the aim of this work was to establish a French expert consensus on management of anal Crohn's disease. These recommendations were led under the aegis of the Société Nationale Française de Colo-Proctologie (SNFCP). They report a consensus on the management of perianal Crohn's disease lesions, including fistulas, ulceration and anorectal stenosis and propose an appropriate treatment strategy, as well as sphincter-preserving and multidisciplinary management. A panel of French gastroenterologists and colorectal surgeons with expertise in inflammatory bowel diseases reviewed the literature in order to provide practical management pathways for perianal CD. Analysis of the literature was made according to the recommendations of the Haute Autorité de Santé (HAS) to establish a level of proof for each publication and then to propose a rank of recommendation. When lack of factual data precluded ranking according to the HAS, proposals based on expert opinion were written. Therefore, once all the authors agreed on a consensual statement, it was then submitted to all the members of the SNFCP. As initial literature review stopped in December 2014, more recent European or international guidelines have been published since and were included in the analysis. MRI is recommended for complex secondary lesions, particularly after failure of previous medical and/or surgical treatments. For severe anal ulceration in Crohn's disease, maximal medical treatment with anti-TNF agent is recommended. After prolonged drainage of simple anal fistula by a flexible elastic loop or loosely tied seton, and after obtaining luminal and perineal remission by immunosuppressive therapy and/or anti-TNF agents, the surgical treatment options to be discussed are simple seton removal or injection of the fistula tract with biological glue. After prolonged loose-seton drainage of the complex anal fistula in Crohn's disease, and after obtaining luminal and perineal remission with anti-TNF±immunosuppressive therapy, surgical treatment options are simple removal of seton and rectal advancement flap. Colostomy is indicated as a last option for severe APL, possibly associated with a proctectomy if there is refractory rectal involvement after failure of other medical and surgical treatments. The evaluation of anorectal stenosis of Crohn's disease (ARSCD) requires a physical examination, sometimes under anesthesia, plus endoscopy with biopsies and MRI to describe the stenosis itself, to identify associated inflammatory, infectious or dysplastic lesions, and to search for injury or fibrosis of the sphincter. Therapeutic strategy for ARSCD requires medical-surgical cooperation.

Use of biological mesh in trans-anal treatment for recurrent recto-urethral fistula.

To report the author's experience on a mini-invasive technique using bioprosthetic plug and a rectal wall flap advancement in the treatment of recurrent recto-urethral fistula. Between 2013 and 2015, seven patients with recurrent recto-urethral fistula were referred to the Pederzoli Hospital, Peschiera del Garda, Verona, Italy. Intraoperatively all patients were found to have a rectal wall lesion and were treated with urinary and fecal diversion. For the persistence of the fistula, all the patients underwent a mini-invasive treatment consisting on placement of a bioprosthetic plug in the fistula covered by an endorectal advancement flap through a trans-anal and trans-urethral combined technique. Median operative time was 48min with a median blood loss of 30ml. Median hospital stay was 3days (IQR 1-3). No case of fistula recurrence or plug migration was described. None of the patients experienced fecal or urinary incontinence. All patients obtained complete fistula healing. Recurrent recto-urethral fistula is a challenging postsurgical complication for surgeons and urologists, and its best treatment is still unknown. Our method seems to be feasible and effective for the treatment of complex recto-urethral fistula.

Rectal advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review and meta-analysis.

Rectal advancement flap is an accepted approach for treating complex fistula-in-ano. However, a diversity of technical modifications have been described. The aim of this study was to evaluate recurrence and fecal continence rates after performing rectal advancement flaps depending upon flap thickness (full-thickness, partial-thickness, or mucosal flaps) and treatment of the fistulous tract (core-out or curettage). Medline (PubMed, Ovid), the Cochrane Library database, and ClinicalTrials.gov were searched. Studies that involved patients with complex cryptoglandular fistulas who had been treated with rectal advancement flaps were included. The outcomes measured were recurrence and fecal continence. All of the statistical analyses were performed using Comprehensive Meta-Analysis software. A fixed model was used if there was no evidence of heterogeneity; otherwise, a random effects model was used. Twenty-six studies were included (1655 patients). The pooled rate of recurrence was 21%. Full-thickness flaps showed the best results concerning recurrence (7.4%), partial flaps revealed 19% and mucosal flaps 30.1%. Core-out and curettage had a similar recurrence (19 vs 21%). Regarding anal incontinence, the pooled rate was 13.3%. Mucosal- and partial-thickness flaps showed similar rates (9.3 vs 10.2%), while full-thickness flaps disturbed it in 20.4%. Most of these alterations were minor symptoms. Otherwise, core-out and curettage showed similar rates (14.3 vs 12%). 1. Full-thickness rectal advancement flaps offer better results regarding the recurrence than mucosal or partial flaps. 2. All flaps cause some incontinence, which increases with the thickness of the flap. 3. The results did not suggest differences in recurrence and incontinence between core-out and curettage.

The changes in resting anal pressure after performing full-thickness rectal advancement flaps

BackgroundAdvancement flap is an accepted approach for treating complex fistula-in-ano.The purpose was to evaluate the changes in resting pressure along the anal canal after performing a full-thickness flap. MethodsManometric review of patients who have undergone a full-thickness rectal advancement flap procedure for complex anal fistulas of cryptoglandular origin. Recurrence and continence were evaluated. Resting Anal Pressure was assessed along the anal canal by two measures: maximum resting pressure(MRP) and inferior resting pressure(IRP) at 0.5 cm from the anal verge. Results119 patients were evaluated. Overall recurrence rate was5.9%. Anal continence was maintained intact in 76.5%. Manometric study showed a significant decrease in postoperative MRP(90.6 ± 31.9 to 45.2 ± 20 mmHg; p < 0.001), while IRP values did not differ significantly(28.2 ± 18.3 to 23.2 ± 13.5 mmHg; p = 0.1). ConclusionsPerforming a full-thickness rectal flap causes a decrease of the MRP in the middle third of the anal canal, due to the inclusion of the internal sphincter in flap. It seems crucial to preserve the distal internal sphincter intact as it helps both to maintain the resting pressure in the lower third and avoid deformities of the anal margin.

Repair of a recurrent traumatic rectovaginal fistula using vaginal wall plication to reinforce a rectal wall advancement flap.

Rectovaginal fistulas (RVF) can cause significant physical discomfort and psychological distress for patients and remain amongst the most challenging disorders for surgeons. A 28-year-old female with a history of a traumatic cloaca repaired 12 years prior was diagnosed with a recurrent RVF and underwent repair using a rectal wall advancement flap reinforced with posterior vaginal wall plication. This case is used to demonstrate surgical technique. The study adhered to the prescribed ethical guidelines. Informed consent was obtained from the patient to use the video recording of her operation for educational purposes. The patient had an uneventful postoperative course. The fistula was fully healed without any signs or symptoms of recurrence at 8 weeks follow-up exam. Her protective ileostomy was successfully closed. Transanal repair of a RVF through creation of a rectal advancement flap and plication of redundant vaginal wall can be used to treat appropriately selected patients with significant tissue defects.

Adapting fistula surgery to fistula tract and patient condition: towards a tailored treatment

Anal fistula remains nowadays a concern for surgeons. It is a complicated disease because it affects the anal sphincters location and infection is always present to some degree. Moreover, surgical treatment should be adapted to fistula characteristics but being aware of patient conditions. Fistula classification, based on preoperative images, and patient continence status before surgery should be kept in mind in the process of choosing the best surgical option. A comprehensive review of the main surgical techniques for an anal fistula of cryptoglandular origin is presented, describing indications, surgical techniques, and results of each type. Setons, fistulotomy and fistulectomy, ligation of intersphincteric fistula tract (LIFT) procedure, rectal advancement flaps, and other preserving sphincter techniques (fibrin glue, anal fistula plug, stem cells, and FilaC) are discussed. An adequate balance between fistula tract surgery with a pleasant treatment of anal sphincters is the key to success, resulting in a high postoperative healing rate (or a low recurrence rate) without continence disturbances. The possibility of choosing between different operations brings the opportunity to the surgeon to perform a tailored fistula treatment.

Gracilis muscle interposition flap repair of urinary fistulae: pelvic radiation is associated with persistent urinary incontinence and decreased quality of life.

The primary goal of urinary fistulae repair is to improve continence and quality of life. Irradiated patients are predisposed to development of bladder outlet dysfunction (BOD), defined as bladder neck contracture or stress urinary incontinence. Here, we review our experience with gracilis flap repairs for rectourinary fistulae (RUF) and urinary cutaneous fistulae (UCF) in patients who underwent pelvic radiation. Twenty-seven patients underwent repair of a RUF/UCF with gracilis flap between 2003 and 2013. Patients were assessed for postoperative fistula closure and BOD, and quality of life was assessed with the Expanded Prostate Index Composite (EPIC) questionnaire administered via telephone at the time of final follow-up. Mean age was 60years (50-73) with median follow-up of 28.7months (1.0-128). Flap failure was noted in 5/20 radiated patients versus 3/7 non-radiated patients (p=0.63). Of the 8 flap failures, 7 underwent secondary repair: repeat gracilis flap (2), coloanal pull-through (2), rectal advancement flap (1), sliding flap (1), and omental flap (1). Median time to revision was 7.2months (3.5-24.9). In irradiated patients, 18/20 (90%) developed BOD compared with 1/7 (14%) who were not radiated (p=0.0006). Radiation was associated with worse scores on the urinary incontinence domain of the EPIC questionnaire compared with non-radiated patients (p=0.0458). Urinary fistula repairs in radiated patients should be undertaken with caution. Even if the fistula is successfully repaired, patients may still have bladder outlet dysfunction and decreased quality of life. Consequently, patients should be counseled about all possible procedures, including permanent urinary diversion as primary therapy.

Robotic Repair of Rectovesical Fistula: Combined Anterior and Posterior Approach with Omental Flap Interposition

Abstract Introduction and Objectives: Rectovesical fistulas are a rare but devastating complication of radical prostatectomy. Management can be challenging due to deep location in the pelvis and recent surgery. We present a case of a patient whose prostatectomy was complicated by unrecognized rectal injury and pelvic abscess. After diverting colostomy, he was referred for management of the resulting rectovesical fistula. The patient failed primary closure with a sliding rectal advancement flap. Methods: In this video, we demonstrate robotic repair of a rectovesical fistula. The fistula tract was first dissected posterior to the bladder. Due to the location of the fistula, a transvesical approach was also required to identify the distal end of the fistula. Once the fistula was completely separated from the bladder, it was primarily closed. An omental flap was then mobilized and secured over the fistula site. Results: The patient underwent successful repair using minimally invasive techniques, preventing th...

Management of cryptoglandular supralevator abscesses in the magnetic resonance imaging era: a case series.

The aim of this study is to describe the diagnostic performance of magnetic resonance imaging in the management of supralevator abscess, regarding its origin, location, drainage route, subsequent treatment of the fistula, and long-term results. A retrospective case series including thirteen consecutive patients with cryptoglandular supralevator abscess treated between 2001 and 2011 at a colorectal unit of a tertiary referral center. A magnetic resonance imaging was performed in all patients before surgical drainage, and its usefulness in assessing supralevator abscess origin was analyzed. Short- and long-term results after drainage were also evaluated. The final diagnosis of supralevator abscess and the location described in the magnetic resonance were confirmed intraoperatively in all patients. An ischiorectal origin was identified in nine patients, and perineal translevator drainage was performed placing a mushroom catheter through the ischiorectal or the postanal space. Four patients underwent secondary treatment of anal fistula: two rectal advancement flap and two non-cutting seton. In the other four patients, an intersphincteric origin was identified and transanal surgical drainage was performed placing a long-term mushroom catheter. Several weeks later, transanal unroofing of the residual cavity was performed and the fistula lay open to the anorectal lumen. In the long-term follow-up (median 61 months), only patients with supralevator abscess of ischiorectal origin in whom fistula was not subsequently treated presented a recurrence of the anal sepsis. Magnetic resonance imaging seems essential to clarify the location of supralevator abscess, its origin, and choice of the right drainage route. Subsequent treatment of the fistula is necessary to avoid recurrence.

Rectourethral Fistula: Systemic Review of and Experiences With Various Surgical Treatment Methods

PurposeA rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation or trauma. Although various surgical procedures for the treatment of an RUF have been described, none has gained acceptance as the procedure of choice. The aim of this study was to review our experience with surgical management of RUF.MethodsThe outcomes of 6 male patients (mean age, 51 years) with an RUF who were operated on by a single surgeon between May 2005 and July 2012 were assessed.ResultsThe causes of the RUF were iatrogenic in four cases (two after radiation therapy for rectal cancer, one after brachytherapy for prostate cancer, and one after surgery for a bladder stone) and traumatic in two cases. Fecal diversion was the initial treatment in five patients. In one patient, fecal diversion was performed simultaneously with definitive repair. Four patients underwent staged repair after a mean of 12 months. Rectal advancement flaps were done for simple, small fistula (n = 2), and flap interpositions (gracilis muscle flap, n = 2; omental flap, n = 1) were done for complex or recurrent fistulae. Urinary strictures and incontinence were observed in patients after gracilis muscle flap interposition, but they were resolved with simple treatments. The mean follow-up period was 28 months, and closure of the fistula was achieved in all five patients (100%) who underwent definitive repairs. The fistula persisted in one patient who refused further definitive surgery after receiving only a fecal diversion.ConclusionDepending on the severity and the recurrence status of RUF, a relatively simple rectal advancement flap repair or a more complex gracilis muscle or omental flap interposition can be used to achieve closure of the fistula.

Can a Flap Help the Plug ? Or Vice Versa ? Proposing a Combined Sphincter-Sparing Anal Fistula Repair

Background : To evaluate the results of a combination of fistulectomy with a rectal advancement flap and an anal fistula plug in the treatment of transsphincteric anal fistulas.Method : All patients with a transsphincteric fistula and a limited number of anterior intersphincteric fistulas in female patients were registered from July 1st, 2010 until November 30th, 2012.All operations were performed by one surgeon (CdG). Patient data and results (healing, continence) were collected in a prospective database.Results : 28 patients were treated with a healing rate of 75% after one procedure. Four out of seven patients who failed to heal underwent a redo anal fistula plug and rectal advancement flap. Three of them were cured. Cumulative healing rate was 86% after two procedures. There were four minor complications. Mean postoperative Wexner score was 0.62. Conclusion : Combination of anal fistula plug and rectal advancement flap in treating transsphincteric anal fistulas can result in good healing rates with minimal incontinence.

Surgical repair of rectovaginal fistulas in patients with Crohn's disease

ObjectivesTo report surgical outcomes of patients who underwent rectovaginal fistula (RVF) repair with a history of Crohn's disease utilizing several reconstructive techniques. Study designRetrospective case series of women (n=6) with Crohn's disease surgically treated with either vaginal or rectal advancement flaps. Demographic information and data specific to Crohn's disease at the time of surgery were collected. In addition, operative reports and postoperative follow-up visits were reviewed. ResultsDuring the study period, six women with the diagnosis of Crohn's disease and RVF underwent surgical management. Five patients had a vaginal advancement flap (VAF) by Female Pelvic Medicine and Reconstructive Surgery and one patient was treated by the rectal advancement flap by Colorectal Surgery. The failure rate in our study population was 33% (2/6). Of note, two of the patients who had a successful VAF had a previous failure after RAF. In addition, four patients who had a repair via the transvaginal approach had a concomitant pedicled flap procedure (i.e. Martius or gracilis flap). The average follow-up for all our patients was 5 months (+/− 6.5 months). No patients failed if they received a VAF with a concomitant flap procedure. ConclusionsThis case series illustrates several techniques utilized for the repair of RVF in patients with Crohn's disease. The use of a bulbocavernosus flap during the primary repair of RVF in this patient population may be considered to bolster the rectovaginal septum.

Biological immunomodulators improve the healing rate in surgically treated perianal Crohn’s fistulas

The role of biological therapy in perianal fistulas associated with Crohn's disease (CD) is uncertain as available data are confused and conflicting. In order to provide some clarity to the issue we have examined a large cohort of patients with perianal fistulas and CD and stratified them according to use of biological agents. Patients with perianal Crohn's fistulas treated between June 1999 and June 2009 were stratified according to use of biological agents and outcome was examined. Healing was defined as absence of fistula or drainage. Prior to surgery perianal sepsis was eradicated with drains or setons. Endpoints were defined as either complete healing, improvement (minimal symptoms and drainage) or unhealed, as noted at subsequent outpatient follow-up. Variables assessed were age, body mass index, smoking, perineal involvement with Crohn's granuloma and type of procedure. Fisher's exact test and χ(2) test were used for analysis. Two hundred and eighteen patients had anal fistulas and CD. Mean follow-up was 3.2±3 years with mean age 38.8±12.2years and body mass index of 25.3±6. One hundred and seventeen patients (53.7%) underwent surgery alone (Group A) and 101 patients (46.3%) underwent surgery and biological immunomodulator treatments (Group B). Demographic data and CD history were similar between groups. Surgeries included seton drainge (n=90), fistulotomy (n=22), rectal advancement flap (n=39), fistulotomy plus seton (n=47) and others (n=20). Overall improvement in Group A was in 42 patients (35.9%) vs 72 patients (71.3%) in Group B (P=0.001). There was no significant difference in other studied variables between both groups. There is a definite role for biological therapy as an adjuvant to surgery in patients with perianal fistulas and CD.

Treatment of a Recurrent Rectourethral Fistula by Using Transanal Rectal Flap Advancement and Fibrin Glue: A Case Report

Rectourethral fistulas (RUFs) in adults are rare and could result from complicated trauma, and prostatic or rectal surgery. RUFs have been treated initially by using primary repair and omental interposition with or without a colostomy during surgery. Recurrent RUFs require complex surgery, such as a low rectal resection and coloanal anastomosis, an interposition flap of the datos muscle or gracilis muscle, and others. Recently, transanal rectal flap advancement and fibrin glue injection have provided an effective occlusion of RUFs. However, no reports about this technique exist for cases of recurrent RUFs. We report a case of a recurrent RUF successfully repaired by using transanal rectal flap advancement combined with fibrin glue injection into the fistula tract. The postoperative course was uneventful without complications. At the 1-year follow-up, no complications such as urethral stricture or recurrence existed, and voiding was normal without anal incontinence.