World Journal of Colorectal Surgery

Transcription

1 World Journal of Colorectal Surgery Volume 3, Issue Article 2 Endorectal Advancement Flap For Complex Fistula-In-Ano Hernan Vaccarezza Agustin Virgili Carlos Alberto Vaccaro Gustavo Leandro Rossi Guillermo Ojea Quintana Hospital Italiano de Buenos Aires, hernanvaccarezza@gmail.com Hospital Italiano de Buenos Aires Hospital Italiano de Buenos Aires Hospital Italiano de Buenos Aires Hospital Italiano de Buenos Aires Copyright c 2013 The Berkeley Electronic Press. All rights reserved.

2 Endorectal Advancement Flap For Complex Fistula-In-Ano Hernan Vaccarezza, Agustin Virgili, Carlos Alberto Vaccaro, Gustavo Leandro Rossi, and Guillermo Ojea Quintana Abstract Purpose: Main goals in treatment of criptoglandular fistula in-ano (CFIA) are to achieve healing and prevent recurrence while preserving sphincteric function. However, surgical treatment of complex fistula in-ano was associated to a high recurrence and postoperative incontinence rate. The aim of this study was to evaluate postoperative outcomes in a series of patients with diagnosis of complex fistula in-ano who underwent endorectal advancement flap procedure (ERAF). Methods: 180 patients with diagnosis of CFIA operated between Jun 2007-Jun 2011 were evaluated. Analyzed variables were sex, age, BMI, type of fistula, number and type of prior anorectal surgery, failure and recurrence rates and postoperative incontinence rate. Results: There were 16 patients (9%) with complex fistula who underwent ERAF, 56% female gender, median age 46. There were 14 high transsphincteric, 1 low transsphincteric and 1 extra sphincteric fistula. 94% of patients had undergone previous anorectal surgery. Median follow-up was 23 months. Overall healing was 81% (13 patients) with an initial failure and recurrence rate of 25% and 6% respectively. Only 5 patients (33%) complained of some degree of incontinence with a median incontinence rate of 2 on Wexner scale. Conclusions: EAF seems to be a reliable procedure in the treatment of complex fistula in-ano, with high healing rate and low recurrence and postoperative incontinence rate. KEYWORDS: fistula-in-ano, complex, endorectal flap, incontinence

3 Vaccarezza et al.: Endorectal Advancement Flap For Complex Fistula-In-Ano 1 ABSTRCT Purpose: Main goals in treatment of criptoglandular fistula in-ano (CFIA) are to achieve healing and prevent recurrence while preserving sphincteric function. However, surgical treatment of complex fistula in-ano was associated to a high recurrence and postoperative incontinence rate. The aim of this study was to evaluate postoperative outcomes in a series of patients with diagnosis of complex fistula in-ano who underwent endorectal advancement flap procedure (ERAF). Methods: 180 patients with diagnosis of CFIA operated between Jun 2007-Jun 2011 were evaluated. Analyzed variables were sex, age, BMI, type of fistula, number and type of prior anorectal surgery, failure and recurrence rates and postoperative incontinence rate. Results: There were 16 patients (9%) with complex fistula who underwent ERAF, 56% female gender, median age 46. There were 14 high transsphincteric, 1 low transsphincteric and 1 extra sphincteric fistula. 94% of patients had undergone previous anorectal surgery. Median follow-up was 23 months. Overall healing was 81% (13 patients) with an initial failure and recurrence rate of 25% and 6% respectively. Only 5 patients (33%) complained of some degree of incontinence with a median incontinence rate of 2 on Wexner scale. Conclusions: EAF seems to be a reliable procedure in the treatment of complex fistula in-ano, with high healing rate and low recurrence and postoperative incontinence rate. Produced by The Berkeley Electronic Press, 2013

4 2 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [2013], Art. 2 BACKGROUND Criptoglandular Fistula-in-ano (CFIA) is a common condition whose presentation can range from a simple and easily treatable superficial fistula to a complex fistula with partial or total involvement of the sphincteric complex. Although it is widely accepted that surgery is the best treatment option for CFIA, post-operative recurrence and incontinence rates reach up 3% to 40% 1-2 and 6% to 45% 3-5 respectively. Many technical options have been described with heterogeneous results. Different procedures include fistulotomy, fistulectomy, Seton placement, fibrin glue injection, Endorectal Advancement flap (EAF) and more recently the use of Biological Fistula Plugs 6-7. The goals of treatment in CFIA are to achieve healing and prevent recurrence while preserving sphincteric function. Superficial fistulas (e.g. intersphincteric, low transsphincteric) can be solved by fistulotomy or fistulectomy. However, the problem is given by those fistulas undertaking extensive involvement of the sphincteric complex (e.g. high trans-sphincteric, supra-sphincteric and extrasphincteric), where the resolution of the disease involves a high risk of postoperative incontinence. Considering these data, the question arises whether these patients should be treated more conservatively by performing a procedure with good postoperative outcomes and low postoperative incontinence rate. In this regards, in recent years there has been a renewed interest in evaluating postoperative results of the ERAF Most of the data come from developed countries Though, the aim of this study was to present the result of ERAF for the treatment of CFIA in a referral centre from Argentina.

5 Vaccarezza et al.: Endorectal Advancement Flap For Complex Fistula-In-Ano 3 METHODS Between 1 Jun 2007 and 1 Jun 2011, 180 patients with diagnose of CFIA were operated at the Hospital Italiano. Sixteen patients (9%) with diagnose of high trans-sphincteric, supra-sphincteric or extrasphincteric fistula underwent ERAF repair. Patients with recto-vaginal, recto-uretral, iatrogenic fistula or secondary to Chron`s disease or malignancy were excluded. Data was obtained from a prospectively maintained database. Analyzed variables were sex, age, BMI, type of fistula, number and type of prior anorectal surgery, failure and recurrence rates and postoperative incontinence rate. Fistulas were classified according to Parks et al criteria 14. Success was considered once external wound had healed with no drainage of previous external opening and symptoms had resolved. Failure of the procedure was defined as absent of wound healing or persistent drainage arising from the same area within first three postoperative months, while recurrence was defined as the reappearance of an abscess or an obvious fistulous track after a period of three months after surgical procedure. Partial failure was defined as persistent discharge arising from primitive external opening in which an evident sinus tract was never exposed. The degree of incontinence was scored on a scale of 1-20 according to Wexner Score System for incontinence 15. Before surgery all patients were evaluated by digital examination in clinic`s office, colonoscopy or rigid proctosigmoidoscopy and magnetic resonance imaging (MRI) when suspecting more than one sinus tract. Preoperatively patients were questioned about incontinence and soiling. Produced by The Berkeley Electronic Press, 2013

6 4 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [2013], Art. 2 Surgical Technique. All operations were performed by the same staff surgeon (G.O.Q) once acute inflammatory symptoms had disappeared. Patient s position depended on internal opening location. While lithotomy position was used for posterior internal opening, jack-knife position was preferred for fistulas with anterior internal opening. Once located, internal opening is resected and closed with interrupted suture of polyglactin 3/0 previous curettage and removal of granulation tissues. Then a semicircular flap consisting of mucosa, submucosa and some muscle fibers is created immediately above and mobilized 3 to 4 centimeters down. The base of the flap is twice width of its base. The flap is then advanced, without tension, and sutured using 3/0 polyglactin just to cover the internal opening. Excess of mucosa is resected in order to avoid ectropion. External opening is resected and external wound is left open ensuring adequate drainage and preventing false closure of the wound that may influence the failure of the procedure. Follow-up. Patients were evaluated on the clinic s office at 1, 2 and 4 weeks and every 3 months in the first postoperative year and some of them were evaluated every 6 months in the second year. Clinical examination was focused on evaluating failure, recurrence and postoperative incontinence. Patients were advised to contact surgical staff if any symptoms appeared during the time between scheduled visits. Statistical analysis. Data was analyzed with the use of fisher test for categorical variables and t-test for continuous variables. Analyses were performed using NCSS software (version 2007,

7 Vaccarezza et al.: Endorectal Advancement Flap For Complex Fistula-In-Ano 5 NCSS Kaysville, Utah, U.S.A). All statistical tests were two-sided and statistical significance was defined as P < RESULTS Demographic data is depicted in table 1. Of the 16 patients included in this period, there were 9 women (56%) and 7 men (44%), median age 46 years old (range 36 to 77). Median Body Mass Index (BMI) was 27.6 Kgs, range 21 to 49. There were 14 high transsphincteric, 1 horseshoe low transsphincteric and 1 horseshoe extrasphincteric fistula. Location of internal opening was posterior 38% (6 patients), anterior 25% (4 patients), right anterolateral 19% (3 patients), left anterolateral 12% (2 patient) and right posterolateral 6% (1 patient). Fifteen patients (93.3%) had previously undergone one or more anorectal surgery with a total of 31 procedures including 11 patients (69%) who underwent perianal abscess drainage, 11 patients (68%) in which a seton was placed and 1 patient (7%) which underwent fistulotomy. One patient had previous history of sphincteroplasty due to fecal incontinence 2 years before. There was a median of 2 procedures for each patient (range 0-4). Median time of follow-up was 23 months with a range of 4 to 36 months. Table 2 shows postoperative results. Complete healing was observed in 81% (13 patients) although initial failure rate was 25% (4 patients). There was no association between failure and internal opening location. Two of these patients underwent new EAF and did well. New EAFs were performed 5-6 months after the inicial flap and once inflammation was settled down. One of these patients had an early false closure of the external wound which determined persistent drainage in the same area of the internal opening within first postoperative month requiring curettage and a new seton placement. Five months later a new EAF was performed. After one year of follow-up there is no evidence of recurrence. The second patient had an early failure on Produced by The Berkeley Electronic Press, 2013

8 6 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [2013], Art. 2 flap`s healing at third postoperative week with persistent fecal discharge trough external opening. Six months later a new EAF with a diverting ostoma was performed. Colostomy was taken down two months later with no evidence of recurrence after 4 years of follow-up. The others two patients with initial failure refused to undergo surgery. One of these was an HIV positive patient who required a diverting colostomy due to perineal sepsis and after a period of 6 months was lost in follow-up. Only one patient had recurrence (6%); a woman 36 years old with no previous relevant medical history who came across with high transsphincteric fistula. She underwent an EAF with no postoperative complication. After a period of 12 months she presented with fecal discharge trough an external opening next to the anal verge requiring colostomy, fistulotomy and sphincteroplasty. After a period of three months, healing was achieved and colostomy was taken down. A total of three patients (20%) needed diverting colostomy. Indications for diverting ostoma were perineal sepsis (1 patient) and fecal discharge trough external opening after initial failure or recurrence (2 patients). In all patients a left sigmoid laparoscopic colostomy was peformed. Colostomies were reversed after a period of 8-12 weeks once complete wound healing was achieved. Postoperative Incontinence and functional outcomes were based on Wexner scale for incontinence. Five patients (33%) complained of some degree of incontinence with a median degree of incontinence of 2, range 1 to 3. Interestingly, patient number 10 was a 63 years old woman with previous medical history of sphincteroplasty due to fecal incontinence. Her Wexner`s score after sphincteroplasty was 0. Two years later she presented with a perianal abscess which required surgical drainage. On surgical examination a high transsphincteric fistula was observed and a seton was left in place. After a period of 2 months seton was removed and an EAF was performed. The patient did well, with no evidence of recurrence after 27 months of follow-up as well as no

9 Vaccarezza et al.: Endorectal Advancement Flap For Complex Fistula-In-Ano 7 postoperative incontinence. Univariate analysis did not shown statically significant difference amongst sex regarding failure, recurrence or postoperative incontinence DISCUSION We present our experience in the management of CFIA with the EAF technique. First described by Noble 16 in 1902 for the treatment of recto-vaginal fistula and then modified by Elting 17, ERAF offers to colorectal surgeon an alternative for the treatment of Complex Criptoglandular Fistula-in-ano with low incidence of postoperative incontinence 9. Main goals in CFIA surgery are to achieve healing, prevent recurrence and avoid postoperative incontinence. Previous reports in literature have shown that Crohn s disease, female gender, recto-vaginal fistula and more than two prior anorectal surgery are predictors of failure in EAF surgery 18. Soltani et al. 9, in a recent review, reported a success rate amongst different series raging from 24% to 100% with a average success of 78.1%. Although some authors reported a higher success rate with mucosal flaps 9, 19, our series with full-thickness flaps showed an acceptable 81% success rate. Variation on postoperative results could be explained by the heterogeneous surgical technique and expertise amongst different centres. Although there is no clear evidence 20, we advocate preoperative seton drainage in order to reduce the inflammatory activity within the tract. Acoording to some authors, preoperative seton drainage benefits are related with a reduction of inflammatory activity within fistulous tract and resolution o secondary tracts 19. In this series 11 patients (68%) underwent preoperative seton drainage while the other 5 patients presented with chronic CFIA treated with loose drainages and no signs of acute inflammatory activity. All seton drainages were left in place until the definitive repair procedure was performed Produced by The Berkeley Electronic Press, 2013

10 8 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [2013], Art. 2 Most common studies limitations are related to an inconsistence definition of failure and recurrence and an inconsistent assessment of postoperative fecal incontinence. Few reports in literature differentiate failure from recurrence 19. We consider failure a completely different event from recurrence. Failure is determined mostly by technical aspects such as excessive flap tension, ischemia, fecal impaction or early false closure of the external wound. On the other hand, most common causes of recurrence are failure to identify and treat internal opening, a lateral internal opening, previous anorectal surgery and presence of secondary sinus tracks poorly drained 21. As been said before, despite having an initial failure rate of 25%, overall success rate achieved was 81%. In this regards, Zimmerman et al. showed that repeat EAF increases overall healing rate of high transsphincteric fistula from 67% after one attempt to 90% after two attempts 22. According to this, in our series 2 of 4 patients with flaps failure underwent a new EAF and achieve healing with no evidence of recurrence after 4 and 36 months after surgery. Furthermore, two patients with partial failure achieve healing 4 and 6 weeks after surgery with no evidence of recurrence after 22 and 36 months of follow-up respectively. Regarding recurrence, our series shows a recurrence rate of 6% (1 patient) with a median time of follow-up of 23 months and only 7% (1 patient) of lost patients. However, reports in literature showed heterogeneous results 1, 11-12, 23 with recurrence rate ranging from 3% o 52% 12, 21, It has been said that healing does not necessarily imply cure 19. One of the most common limitations in evaluating recurrence rate is determined by the percentage of lost patients and the length of follow-up. In this regards, Golub et al. 12 reported a recurrence rate of 3%, however more than 60% of patients were lost in follow-up. Length of follow-up required is not well established. While some authors 23, argue that extending follow-up beyond 1 year after surgery

11 Vaccarezza et al.: Endorectal Advancement Flap For Complex Fistula-In-Ano 9 is not necessary, others support the idea that recurrence can be expected beyond this period 12, Furthermore, van der Hugen et al. 19 reported, in a series with a median follow-up of 72 months a recurrence rate of 22%, 44% and 63% at 12, 24 and 48 months after surgery, respectively. This increase of recurrence with time could determine a misleading initial recurrence rate. According to this, the only recurrence of our series appeared 12 months after surgery. Assessing postoperative incontinence had remarkable importance when evaluating quality of life. However, in most reports in literature there is a lack of a standardized method to determine postoperative incontinence 9, 12, 18, 21, 27. The Wexner scale is a reliable, consistent and widely used instrument for assessing symptoms of severity in patient with fecal incontinence. Reported incontinence vary between 0% and 35% with an average incontinence rate of 13.2% 9. In our series 5 patients complained of some degree of incontinence, however the median degree of incontinence on Wexner scale was 2 (range 1 to 3) and all patients had score 0 on lifestyle alterations. In conclusion, our series has its strength on a 93% of follow-up with an overall success rate over the average reported in literature, a clear differentiation between failure and recurrence and a consistent assessment of postoperative incontinence. Despite the small sample size of our series of EAF seems to be a reliable procedure in the treatment of complex fistula in-ano, with high healing rate and low recurrence and postoperative incontinence rate. Produced by The Berkeley Electronic Press, 2013

12 10 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [2013], Art. 2 References 1. Ramanujam PS, Prasad ML, Abcarian H, Tan AB. Perianal abscesses and fistulas. A study of 1023 patients. Dis Colon Rectum Sep;27(9): Schouten WR, van Vroonhoven TJ. Treatment of anorectal abscess with or without primary fistulectomy. Results of a prospective randomized trial. Dis Colon Rectum Jan;34(1): Bennett RC. A review of the results of orthodox treatment for anal fistulae. Proc R Soc Med Sep;55: Sainio P, Husa A. Fistula-in-ano. Clinical features and long-term results of surgery in 199 adults. Acta Chir Scand. 1985;151(2): Vasilevsky CA, Gordon PH. Results of treatment of fistula-in-ano. Dis Colon Rectum Apr;28(4): Champagne BJ, O'Connor LM, Ferguson M, Orangio GR, Schertzer ME, Armstrong DN. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum Dec;49(12): Safar B, Jobanputra S, Sands D, Weiss EG, Nogueras JJ, Wexner SD. Anal fistula plug: initial experience and outcomes. Dis Colon Rectum Feb;52(2): Ortiz H, Marzo J, Ciga MA, Oteiza F, Armendariz P, de Miguel M. Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano. Br J Surg Jun;96(6): Soltani A, Kaiser AM. Endorectal advancement flap for cryptoglandular or Crohn's fistula-in-ano. Dis Colon Rectum Apr;53(4): Uribe Quintana N, Aguado Perez M, Minguez Perez M, Ortiz Tarin I, Millan Scheiding M, Martin Dieguez MC, et al. [Impact of endorectal advancement flaps in fecal incontinence]. Cir Esp Oct;86(4): Dixon M, Root J, Grant S, Stamos MJ. Endorectal flap advancement repair is an effective treatment for selected patients with anorectal fistulas. Am Surg Oct;70(10): Golub RW, Wise WE, Jr., Kerner BA, Khanduja KS, Aguilar PS. Endorectal mucosal advancement flap: the preferred method for complex cryptoglandular fistula-in-ano. J Gastrointest Surg Sep-Oct;1(5): Stone JM, Goldberg SM. The endorectal advancement flap procedure. Int J Colorectal Dis Dec;5(4): Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg Jan;63(1): Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum Jan;36(1): Noble GH. A New operation for complete laceration of the perineum. Designed for the purpose of eliminating danger of infection from the rectum.. Journal of American Medical Association. 1902;XXXIX(6): Elting AW. X. The Treatment of Fistula in Ano: With Especial Reference to the Whitehead Operation. Ann Surg Nov;56(5): Mizrahi N, Wexner SD, Zmora O, Da Silva G, Efron J, Weiss EG, et al. Endorectal advancement flap: are there predictors of failure? Dis Colon Rectum Dec;45(12): van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG. Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas: recurrent perianal fistulas: failure of treatment or recurrent patient disease? Int J Colorectal Dis Dec;21(8):

13 Vaccarezza et al.: Endorectal Advancement Flap For Complex Fistula-In-Ano Mitalas LE, van Wijk JJ, Gosselink MP, Doornebosch P, Zimmerman DD, Schouten WR. Seton drainage prior to transanal advancement flap repair: useful or not? Int J Colorectal Dis Dec;25(12): Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum Jul;39(7): Mitalas LE, Gosselink MP, Zimmerman DD, Schouten WR. Repeat transanal advancement flap repair: impact on the overall healing rate of high transsphincteric fistulas and on fecal continence. Dis Colon Rectum Oct;50(10): Ortiz H, Marzo M, de Miguel M, Ciga MA, Oteiza F, Armendariz P. Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano. Br J Surg Apr;95(4): Christoforidis D, Pieh MC, Madoff RD, Mellgren AF. Treatment of transsphincteric anal fistulas by endorectal advancement flap or collagen fistula plug: a comparative study. Dis Colon Rectum Jan;52(1): van Koperen PJ, Bemelman WA, Gerhards MF, Janssen LW, van Tets WF, van Dalsen AD, et al. The anal fistula plug treatment compared with the mucosal advancement flap for cryptoglandular high transsphincteric perianal fistula: a double-blinded multicenter randomized trial. Dis Colon Rectum Apr;54(4): Athanasiadis S, Helmes C, Yazigi R, Kohler A. The direct closure of the internal fistula opening without advancement flap for transsphincteric fistulas-in-ano. Dis Colon Rectum Jul;47(7): Ozuner G, Hull TL, Cartmill J, Fazio VW. Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum Jan;39(1):10-4. Legends Figure 1. Endorectal advancement flap procedures between Jun-2007 and Jun-2011 Figure 2. High trans-sphincteric fistula with posterior internal opening Figure 3. Mucosal flap is mobilized down to cover internal opening. Figure 4. External opening is resected and external wound is left open Produced by The Berkeley Electronic Press, 2013

14 12 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [2013], Art. 2 Table 1. Patient`s demography Data Nº of patients (%) Female gender 9 (56%) Type of Fistula Transsphincteric Extrasphincteric 15 (94%) 1 (6%) Internal opening Posterior Anterior Right antero-lateral Left antero-lateral Right postero-lateral 6 (38 %) 4 (25%) 3 (19%) 2 (12%) 1 (6 %) Previous Anorectal Surgery 15 (94%) Table 2. Previous anorectal surgery and Wexner score for incontinence Patient N of previous procedures Abscess Drainage Seton Placement Fistulotomy Postoperative incontinence 1 2 X X X XXX XX X X XX X XX X X X X X X X X X X x 0

15 Vaccarezza et al.: Endorectal Advancement Flap For Complex Fistula-In-Ano 13 Table 3. Post-operative outcomes Data Nº of patients (%) Overall Healing 13 (81 %) Initial Failure rate 4 (25%) Recurrence rate 1 (6%) Post-operative incontinence Median degree of incontinence (Range) 5 (33%) 2 (1-3) Figure 1. Figure 2. Produced by The Berkeley Electronic Press, 2013

16 World Journal of Colorectal Surgery 14 Figure 3. Figure 4. Vol. 3, Iss. 2 [2013], Art. 2

17 Vaccarezza et al.: Endorectal Advancement Flap For Complex Fistula-In-Ano 15 Produced by The Berkeley Electronic Press, 2013

18 16 World Journal of Colorectal Surgery Vol. 3, Iss. 2 [2013], Art. 2