David D. E. Zimmerman

Transanal advancement flap repair of transsphincteric fistulas

OBJECTIVE: The purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after transanal advancement flap repair and to examine the impact of this procedure on fecal continence. METHODS: Between January 1992 and January 1997, 44 consecutive patients with a transsphincteric perianal fistula passing through the middle or upper third of the external anal sphincter underwent transanal advancement flap repair. There were 34 male patients, and the median age was 44 (range, 19–72) years. Twenty-four patients (55 percent) had previously undergone one or more prior attempts at repair. With the patient in prone jackknife position, the internal opening of the fistula was exposed using a Parks retractor. The crypt-bearing tissue around the internal opening and the overlying anoderm was excised. A layer of mucosa, submucosa, and internal sphincter fibers was mobilized 4 to 6 cm proximally. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the anoderm below the level of the internal opening. The median follow-up was 12 months. Fecal continence was evaluated in 43 patients by means of a questionnaire. RESULTS: Transanal advancement flap repair was successful in 33 patients (75 percent). Success was inversely correlated with the number of prior attempts. In patients with no or only one previous attempt at repair the healing rate was 87 percent. In patients with two or more previous repairs the healing rate dropped to 50 percent. In 15 patients (35 percent) continence deteriorated after transanal advancement flap repair. Twenty-six patients (59 percent) had a completely normal continence preoperatively. Ten of these patients (38 percent) encountered soiling and incontinence for gas after the procedure, whereas three subjects (12 percent) complained of accidental bowel movements. Eighteen patients (41 percent) had continence disturbances at the time of admission to our hospital. In two of these patients (11 percent), incontinence deteriorated. CONCLUSIONS: The results of transanal advancement flap repair in patients with no or only one previous attempt at repair are good. In patients who have undergone two or more previous attempts at repair the outcome is less favorable. Remarkably, the number of previous attempts did not adversely affect continence status.

Anocutaneous advancement flap repair of transsphincteric fistulas.

PURPOSE: The purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after anocutaneous advancement flap repair and to examine the impact of this procedure on fecal continence. METHODS: Between January 1997 and June 1999, 26 consecutive patients with a transsphincteric perianal fistual passing through the middle or upper third of the external anal sphincter underwent anocutaneous advancement flap repair. There were six female patients, and the median age was 39 (range, 27–54) years. Twenty patients (77 percent) had previously undergone one or more prior attempts at repair. With the patient in the prone-jackknife position, the internal opening of the fistual was exposed using a Lone Star Retractor System, and the crypt-bearing tissue around the internal opening as well as the overlying anoderm was excised. An (inverted) U-shaped flap, including perianal skin and fat, was created. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the mucosa and underlying internal anal sphincter proximal to the closed internal opening. The median follow-up time was 25 months. Fecal continence was evaluated in 23 patients by means of a questionnaire. RESULTS: Anocutaneous advancement flap repair was successful in 12 patients (46 percent). Success was inversely correlated with the number of prior attempts. In patients who had undergone no or only one previous attempt at repair (n=9), the healing rate was 78 percent. In patients with two or more previous repairs (n=17) the healing rate was only 29 percent. In seven patients (30 percent) continence deteriorated after anocutaneous advancement flap repair. Eleven patients (48 percent) had a completely normal continence preoperatively. Two of these patients (18 percent) encountered soiling and incontinence for gas after the procedure, whereas two subjects (18 percent) complained of accidental bowel movements. Twelve patients (52 percent) presented with continence disturbances at the time of admission to our hospital. In this group, deterioration was observed in two patients (17 percent). CONCLUSION: The results of anocutaneous advancement flap repair in patients with no or only one previous attempt at repair are moderate. In patients who have undergone two or more previous attempts at repair the outcome is poor. Based on the relatively low healing rate and deterioration of continence, this procedure seems less suitable for high transsphincteric fistulas than transanal mucosal advancement flap repair.

Prospective comparison of hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging of perianal fistulas.

AbstractPURPOSE: This study was conducted to determine agreement between hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in the preoperative assessment of perianal fistulas and to compare these results with the surgical findings. METHODS: Twenty-one patients (aged 26–71 years) with clinical symptoms of a cryptoglandular perianal fistula and a visible external opening underwent preoperative hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography, endoanal magnetic resonance imaging, and surgical exploration. The results were assessed separately by experienced observers blinded as to each other’s findings. Each fistula was described with notice of the following characteristics: classification of the primary fistula tract according to Parks (intersphincteric, transsphincteric, extrasphincteric, or suprasphincteric), horseshoe, or not classified; presence of secondary tracts (circular or linear); and location of an internal opening. RESULTS: The median time between hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging was 66 (interquartile range, 21–160) days; the median time between the last study (hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography or endoanal magnetic resonance imaging) and surgery was 154 (interquartile range, 95–189) days. Agreement for the classification of the primary fistula tract was 81 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 90 percent for endoanal magnetic resonance imaging and surgery, and 90 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging. For secondary tracts, agreement was 67 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 57 percent for endoanal magnetic resonance imaging and surgery, and 71 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in case of circular tracts and 76 percent, 81 percent, and 71 percent, respectively, in case of linear tracts. Agreement for the location of an internal opening was 86 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 86 percent for endoanal magnetic resonance imaging and surgery, and 90 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging. CONCLUSIONS: For evaluation of perianal fistulas, hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging have good agreement, especially for classification of the primary fistula tract and the location of an internal opening. These results also show good agreement compared with surgical findings. Therefore, hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging can both be used as reliable methods for preoperative evaluation of perianal fistulas.

Long-term follow-up of retrograde colonic irrigation for defaecation disturbances

Objective  Irrigation of the distal part of the large bowel is a nonsurgical alternative for patients with defaecation disturbances. In our institution, all patients with defaecation disturbances, not responding to medical treatment and biofeedback therapy, were offered retrograde colonic irrigation (RCI). This study is aimed at evaluating the long‐term feasibility and outcome of RCI.

Repeat transanal advancement flap repair: Impact on the overall healing rate of high transsphincteric fistulas and on fecal continence

PurposeTransanal advancement flap repair (TAFR) has been advocated as the treatment of choice for transsphincteric fistulas passing through the upper or middle third of the external anal sphincter. It is not clear whether previous attempts at repair adversely affect the outcome of TAFR. The purpose of the present study was to evaluate the success rate of a repeat TAFR and to assess the impact of such a second procedure on the overall healing rate of high transsphincteric fistulas and on fecal continence.MethodsBetween January 2001 and January 2005, a consecutive series of 87 patients (62 males; median age, 49 (range, 27–73) years) underwent TAFR. Median follow-up was 15 (range, 2–50) months. Patients in whom the initial operation failed were offered two further treatment options: a second flap repair or a long-term indwelling seton drainage. Twenty-six patients (male:female ratio, 5:2; median age, 51 (range, 31–72) years) preferred a repeat repair. Continence status was evaluated before and after the procedures by using the Rockwood Faecal Incontinence Severity Index (RFISI).ResultsThe healing rate after the first TAFR was 67 percent. Of the 29 patients in whom the initial procedure failed, 26 underwent a repeat TAFR. The healing rate after this second procedure was 69 percent, resulting in an overall success rate of 90 percent. Both before and after the first attempt of TAFR, the median RFISI was 7 (range, 0–34). In patients who underwent a second TAFR, the median RFISI before and after this procedure was 9 (range, 0–34) and 8 (range, 0–34), respectively. None of these changes were statistically significant.ConclusionsRepeat TAFR increases the overall healing rate of high transsphincteric fistulas from 67 percent after one attempt to 90 percent after two attempts without a deteriorating effect on fecal continence.

The outcome of transanal advancement flap repair of rectovaginal fistulas is not improved by an additional labial fat flap transposition

Abstract Transanal advancement flap repair (TAFR) has been advoated as the treatment of choice for patients with low rectovaginal fistulas. Recently, several studies have reported a significantly lower healing rate. We also encountered low healing rates after TAFR. In an attempt to improve our results, we added labial fat flap transposition (LFFT) to the TAFR of rectovaginal fistulas. The aim of the present study was to evaluate the outcome after TAFR and to investigate the impact of an additional LFFT. Between 1991 and 1997, 21 consecutive patients of median age 33 years underwent TAFR. The etiology of the fistulas was: obstetric injury (n=9), cryptoglandular abscess (n=8) and wound infection after anterior anal repair (n=4). The first 9 patients underwent TAFT with (n=3) or without (n=6) anterior anal repair. In the following 12 patients, LFFT was added to the advancement flap. In 4 of these a concomitant anterior anal repair was performed. The median follow-up was 15 months. The overall healing rate was 48%. In the first 9 patients, in whom no additional LFFT was performed, the rectovaginal fistula healed in 4 cases (44%). In the following 12 patients in whom an additional LFFT was performed, a similar healing rate was observed (50%). In conclusion, the outcome of transanal advancement flap repair of rectovaginal fistulas is poor. Addition of a labial fat flap transposition does not improve this outcome.

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

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

Transanal minimally invasive surgery: initial experience and short-term functional results.

BACKGROUND: Currently, the preferred method for local excision of rectal polyps is transanal endoscopic microsurgery, avoiding rectal resection. Transanal minimally invasive surgery is a relatively new technique using a disposable port in combination with conventional laparoscopic instruments. This method is less expensive as compared with transanal endoscopic microsurgery, relatively easy to learn, and available. Despite wide adoption of transanal minimally invasive surgery, to date only a few series on the implementation and use of this technique are reported, and detailed information on the effect of transanal minimally invasive surgery on fecal continence is not available. OBJECTIVE: The purpose of this work was to prospectively assess the functional outcome after transanal minimally invasive surgery using the Fecal Incontinence Severity Index preoperatively and postoperatively. DESIGN: This was a prospective cohort study. SETTINGS: The study was conducted at a large teaching hospital. PATIENTS: Patients included those who underwent transanal minimally invasive surgery between October 2011 and September 2013. INTERVENTIONS: Transanal minimally invasive surgery was studied. MAIN OUTCOME MEASURES: We measured postoperative surgical and functional results. RESULTS: A total of 37 patients underwent transanal minimally invasive surgery during our study period. Short-term morbidity rate was 14%, and positive resection margins were reported in 6 cases (16%); in 1 of these patients, a local recurrence was observed. Overall, there was a significant decline in preoperative and postoperative Fecal Incontinence Severity Index scores (p = 0.02), indicating an improvement in anorectal function after transanal minimally invasive surgery for patients with impaired preoperative continence. Seventeen patients (49%) had impaired continence before transanal minimally invasive surgery (mean Fecal Incontinence Severity Index score = 21). Continence improved in 15 (88%) of these patients after surgery; no change was observed in 1 patient (6%), and continence further decreased in another. In addition, 18 patients (51%) had normal preoperative continence (Fecal Incontinence Severity Index score = 0), of which 83% had no change in functionality, and continence decreased in 3. LIMITATIONS: No quality of life was measured. CONCLUSIONS: Short-term functional results of transanal minimally invasive surgery for rectal polyps are excellent and comparable to functional results using the dedicated transanal endoscopic microsurgery equipment. More research on outcome after transanal minimally invasive surgery is needed to assess morbidity rates and oncologic clearance.

Treatment of Chronic Anal Fissure by Application of l-Arginine Gel: A Phase II Study in 15 Patients

PURPOSELocal application of exogenous nitric oxide donors, such as isosorbide dinitrate and glyceryl trinitrate, promotes fissure healing by reducing anal resting pressure and improving anodermal blood flow. The major drawback of these nitric oxide donors is headache. The overall incidence of this side effect is approximately 40 percent. Recently we have shown in healthy volunteers that l-arginine, being an intrinsic precursor of nitric oxide, reduces anal resting pressure without headache as a side effect. The aim of the pres-ent study was to evaluate the effect of l-arginine on anal resting pressure, anodermal blood flow, and fissure healing in patients with chronic anal fissure.METHODSFifteen patients with a chronic anal fissure were included in the present study. Before entering the study 10 patients were unsuccessfully treated by local application of isosorbide dinitrate. Six of these patients experienced severe headache during treatment with isosorbide dinitrate. All patients were treated for at least 12 weeks by local application of a gel containing l-arginine 400 mg/ml five times a day. In patients with a persistent fissure, treatment was continued until 18 weeks. Anal manometry and laser Doppler flowmetry of the anoderm were performed before treatment, 20 minutes after local application of the first dose, and after 12 weeks of treatment. A visual analog scale was used to assess fissure-related pain and headache.RESULTSOne patient dropped out after one day of treatment, and one was excluded because of violation of the study protocol. After 12 weeks of treatment complete fissure healing was observed in 3 of 13 (23 percent) patients, and after 18 weeks the healing rate was 8 of 13 (62 percent) patients. None of the 13 patients experienced typical nitric oxide-induced headache. The pressure recordings showed a significant reduction of maximum anal resting pressure (mean ± SD): pretreatment 89 ± 17 mmHg; 20 minutes after application of the first dose 67 ± 17 mmHg; 12 weeks after treatment 74 ± 14 mmHg (P < 0.005). Recordings of anodermal blood flow showed a significant increase in flow: pretreatment 0.36 ± 0.25 volts; 20 minutes after application of the first dose 0.59 ± 0.27; 12 weeks after treatment 0.64 ± 0.33 (P < 0.005).CONCLUSIONSLocal application of l-arginine promotes fissure healing without headache as a side effect, and l-arginine is effective even in patients not responding to isosorbide dinitrate treatment.

Impact of two different types of anal retractor on fecal continence after fistula repair

PurposeThis study was designed to compare two different types of anal retractors (Parks vs. Scott) with regard to their impact on fecal continence after fistula repair. METHODS: Between November 2000 and November 2001, 30 patients were randomized into two groups. In Group A (n = 15), a Parks retractor was used during fistula repair, whereas in Group B (n = 15), the repair was performed with a Scott retractor. Before and three months after surgery, maximum anal resting pressure and maximum anal squeeze pressure were recorded. In addition, continence status was evaluated using both the Rockwood Fecal Incontinence Severity Index and the scoring system according to Parks. RESULTS: In Group A, the median anal resting pressure dropped from 76 mmHg to 42 mmHg. In Group B, no significant difference was observed between the preoperative and postoperative anal resting pressure. The difference in the changes from baseline between the two groups was statistically significant (P = 0.035). No significant changes in anal squeeze pressure were observed. In Group A, the median Rockwood fecal incontinence score increased from 0 to 12. In Group B, the median Rockwood fecal incontinence score did not change after the operation. The difference between the two groups was statistically significant (P = 0.038). CONCLUSIONS: The use of a Parks retractor during perianal fistula repair has a deteriorating effect on fecal continence, probably because of damage to the internal anal sphincter. Because this side effect was not observed after the use of a Scott retractor, we advocate the use of this retractor during all fistula repairs.