Advancement flaps for fistula in ano

SR Brown

Sheffield teaching hospitals

Perfect operation

• Easy to perform

• No risk of incontinence

• Effective

History

• First proposed 1902 (Noble) for rectovaginal fistulae

• Anal fistulae 1912 (Elting)

Objectives

• Indications

• Types and Techniques

• Results

Indications

• High trans-sphincteric/supra-sphincteric fistulae

• Anterior fistulae in women

• Rectovaginal fistulae

• (Crohn’s)

Contraindications

• Acute presentation

• Large opening

• Rectal disease– Neoplasia– Crohn’s– Radiation

Types of advancement flap

• Endorectal– Full thickness– Partial thickness– mucosal

• Anocutaneous– V-Y,Y-V– Rhomboid, House

Method

• Bowel preparation

• Antibiotics

• Position

Essential steps

• Excision of internal opening

• Excision primary tract

• Formation flap

• Attention to external component

Excision fistula tract

• Sharp dissection core out/curettage

• Excise secondary tracts

• Continue to internal sphincter/complete tract

Mobilisation rectal flap

• Adrenaline (1:300,000)

• Partial/full thickness internal sphincter flap (based proximally)

• Divergent lateral incisions

• Meticulous haemostasis

• Excise internal opening +/- closure internal tract

Suturing flap

• Suture with absorbable Vicryl 2/0

• Tension free

• Leave external opening to drain/Malecot catheter/glue

• No indication for bowel confinement/stoma

Principles for success

• Stagger the mucosal and muscular suture line

• Width of base of flap > twice the apex

• No sepsis

ResultsDifficulties

• Due to– Population

• Inflammatory/Non inflammatory

• High/low fistulae

• Recurrent

– Surgeon– Follow up– Thoroughness of reporting

ResultsEndorectal Technique

Study Year No. pts. Recurrence (%)

Incontinence

(%)

Oh 1983 15 13 -

Aguilar 1985 151 2 10

Athanasiadas 1994 169 20 21

Schouten 1999 44 25 35

Ortiz 2000 91 7 8

Mizrahi 2002 66 33 9

Sonoda 2002 55 25 -

Dixon 2004 29 17 -

Reasons for Incontinence

• Direct damage to sphincter

• Stretching

• Scarring

• Decreased sensation

The anocutaneous flap

ResultsAnocutaneous technique

Study Year No Patients Recurrence

(%)

Incontinence

(%)

Del Pino 1996 11 27 -

Nelson 2000 73 23 16

Zimmerman 2001 26 54 30

Amin 2003 18 17 -

Sungertekin 2004 65 9 0

Factors that influence healing

• Redo procedures

• Crohn’s

• Rectovaginal fistulas

• Smoking

Summary

• Advancement flaps useful part of armamentarium for fistulas

• Techniques equally effective

• Consent for recurrences/incontinence particularly certain groups

Rectovaginal fistulaecauses

• Inflammatory– Crohn’s– Neoplastic– Post-radiotherapy

• Non inflammatory– obstetric

Rectovaginal fistulaetypes

Types of repair

• Transanal advancement flap

• Lay open and primary repair (perineoproctotomy)

• Transperineal repair (+/- transposition)

• Transvaginal repair