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Rectal Mucosa Advancement Flaps: Do they work?
Matthew Sherman1, Steven Schechter2, Jorge Lagares2, Adam Klipfel2, Matthew Vrees1
1Rhode Island Colorectal Clinic/Roger Williams Medical Center, Pawtucket, RI;2Rhode Island Colorectal Clinic/Brown University, Pawtucket, RI
Objective: Evaluate the outcome in patients with transphincteric fistulas following rectal mucosal advancement flap (RMAF) with and without fibrin glue as opposed to tradition methods that may cause sphincter injuries.
Design: Prospective Cohort
Setting: Private practice colorectal surgery clinic, hospitalized care
Patients: Consecutive sample of 32 patients with transphincteric fistulas from 1998-2006. Four horseshoe fitulas excluded, leaving 28 patients for analysis.
Interventions: RMAF, with or without fibrin glue
Main Outcome Measures: Patient demographics, surgical history and outcomes were collected and analyzed to evaluate the effectiveness of RMAF in the treatment of anal fistulas.
Results: Primary success in 50% of patients. Overall rate of cure after additional intervention was 86%. These procedures included repeat RMAF, seton placement, second stage fistulotomy, fibrin glue and fibrin plug fitulotomy. Ten out of fourteen failures underwent seton placement. Three of these setons were cutting of which two led to healing (67%) and seven were placed as a precursor to a repeat RMAF, secondary fistulotomy, fibrin plug or fibrin glue placement, all of which healed (100%). Of the four horseshoe fistulas excluded from the study, three out of four treated with RMAF initially healed one of the two fistula tracts, but required additional interventions for healing of the second tract.
Conclusions: RMAF has given the surgeon a chance to cure complex anal fistulas without damaging the anorectal sphincter mechanism. Although the primary success rate is fair, additional surgical procedures can yield an overall good result. Surgeons should attempt RMAF as the initial treatment for transphincteric fistulas.
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