Endoanal advancement flap repair for complex anorectal fistulas

Most anorectal fistulas may be safely and reliably treated by fistulotomy. However, certain complex fistulas (e.g., rectovaginal fistulas, high transsphincteric tracts, Crohn's disease) are not well suited to this technique. Few satisfactory alternatives exist. The aim of this study was to assess the utility of endoanal advancement flap repair for these difficult fistulas.

Thirty-three consecutive patients underwent endoanal advancement flap repair of a complex anorectal fistula. Patients were followed up via a prospective database. Demographic information, the presence of previous fistula surgery, and surgical complications were noted. Patients were closely followed up until healing of the fistula or treatment failure was noted.

The overall initial healing rate was 81% (27 of 33). However, 3 patients with perianal Crohn's disease ultimately developed a recurrent fistula. There were no major complications and two minor urinary complications. No patient required hospital readmission, and there were no new problems with fecal incontinence. No patient required a colostomy.

Endoanal advancement flap repair is effective in a variety of difficult, complicated anorectal fistulas. Since the morbidity is quite low, it should be attempted prior to fecal diversion, when possible, in these settings.