John W. Briel

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.

Smoking affects the outcome of transanal mucosal advancement flap repair of trans-sphincteric fistulas

The aim of the study was to identify variables affecting the outcome of transanal advancement flap repair (TAFR) for perianal fistulas of cryptoglandular origin.

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.

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.

Clinical outcome of anterior overlapping external anal sphincter repair with internal anal sphincter imbrication.

Fecal incontinence caused by overt anterior sphincter defects sustained during childbirth is usually treated by a delayed overlapping repair of the external anal sphincter. However, an obstetric trauma is frequently associated with disruption of the perineal body and loss of the distal rectovaginal septum. Data regarding a combined repair, consisting of restoration of the rectovaginal septum and perineal body, overlapping external anal sphincter repair, and imbrication of the internal anal sphincter, are scanty. PURPOSE: This prospective study was aimed at the following: 1) evaluating the clinical outcome of such an anterior anal repair in patients with fecal incontinence caused by obstetric trauma; 2) comparing the functional results with those obtained in a historical group of patients who underwent a conventional direct sphincter repair. METHODS: During the period between 1973 and 1989, 24 female patients (median age, 44 (range, 28–67) years) with fecal incontinence underwent direct sphincter repair (Group I). During the period between 1989 and 1994, a consecutive series of 31 female patients (median age, 46 (range, 23–78) years) with fecal incontinence underwent anterior anal repair (Group II). RESULTS: At two years of follow-up, continence had been restored in 15 patients (63 percent) in Group I, whereas restoration of continence was successful in 21 patients (68 percent) in Group II. CONCLUSION: The more complex anterior anal repair fails to confer clinical benefit compared with the rather simple direct sphincter repair.

Clinical value of colonic irrigation in patients with continence disturbances

Continence disturbances, especially fecal soiling, are difficult to treat. Irrigation of the distal part of the large bowel might be considered as a nonsurgical alternative for patients with impaired continence. PURPOSE: This study is aimed at evaluating the clinical value of colonic irrigation. METHODS: Thirty-two patients (16 females; median age, 47 (range, 23–72) years) were offered colonic irrigation on an ambulatory basis. Sixteen patients suffered from fecal soiling (Group I), whereas the other 16 patients were treated for fecal incontinence (Group II). Patients were instructed by enterostomal therapists how to use a conventional colostomy irrigation set to obtain sufficient irrigation of the distal part of their large bowel. Patients with continence disturbances during the daytime were instructed to introduce 500 to 1,000 ml of warm (38°C) water within 5 to 10 minutes after they passed their first stool. In addition, they were advised to wait until the urge to defecate was felt. Patients with soiling during overnight sleep were advised to irrigate during the evening. To determine clinical outcome, a detailed questionnaire was used. RESULTS: Median duration of follow-up was 18 months. Ten patients discontinued irrigation within the first month of treatment. Symptoms resolved completely in two patients. They believed that there was no need to continue treatment any longer. Irrigation had no effect in two patients. Despite the fact that symptoms resolved, six patients discontinued treatment because they experienced pain (n=2) or they considered the irrigation to be too time-consuming (n=4). Twenty-two patients are still performing irrigations. Most patients irrigated the colon in the morning after the first stool was passed. Time needed for washout varied between 10 and 90 minutes. Frequency of irrigations varied from two times per day to two times per week. In Group I, irrigation was found to be beneficial in 92 percent of patients, whereas 60 percent of patients in Group II considered the treatment as a major improvement to the quality of their lives. If patients who discontinued treatment because of washout-related problems are included in the assessment of final outcome, the success rate is 79 and 38 percent respectively. CONCLUSIONS: Patients with fecal soiling benefit more from colonic irrigation than patients with incontinence for liquid or solid stools. If creation of a stoma is considered, especially in patients with intractable and disabling soiling, it might be worthwhile to treat these patients first by colonic irrigation.

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.

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.