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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 41 | Anocutaneous Advancement Flap Repair of Transsphincteric Fistulas [2001년 10월 DCR] | 2011-11-17 | 3412 |
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David D. E. Zimmerman, John W. Briel, M.D., Martijn P. Gosselink, W. Rudolf Schouten, M.D., Ph.D.
From the Colorectal Research Group of the Department of Surge~, Erasmus Medical Center Rotlerdam,
Rotlerdam, the Netherlands 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 fistula 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 fistula 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 (1: = 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%) 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 tess suitable for high transsphincteric fistulas than transanal mucosal advancement flap repair. A transsphincteric fistula, running through the lower third of the external anal sphincter can be
cured in most cases by a simple "laying-open" technique. This procedure is less appropriate for fistulas running through the middle and upper third of the external anal sphincter. In case of such a high transsphicteric fistula, transsection and subsequent separation of both sphincters will inevitably lead to impaired continence. Although incontinence for solid stool is rare, the reported incidence of minor continence disorders such as soiling, incontinence for gas or liquid stool is rather high, varying between 30 and 50 percent. It has been reported that transanal mucosat advancement flap repair is an attractive alternative for patients with a high transsphincteric fistula. In a recent study it has been shown that the results of this procedure are good in patients with no, or only one previous attempt at repair. In patients who have undergone two or more previous attempts at repair the outcome is less favorable. This study also revealed that continence deteriorated in 35 percent of the patients after transanal mucosal advancement flap repair. A few years ago, anocutaneous advancement flaps were introduced in the treatment of high transsphincteric fistulas. The results, reported so far, seem to be comparable with those obtained after transanal mucosal advancement flap repair. Some investigators advocate anocutaneous advancement flap repair, because this procedure does not result in anatomic alterations of the anal canal. The anocutaneous advancement flap repair can be performed without deep intra-anal dissection. This might be a major advantage, resulting in less sphincter damage. We were interested in the impact of this procedure on fecal continence. Therefore we conducted a prospective study in a consecutive series of 26 patients with a high transsphincteric fistula to evaluate the healing rate and to examine fecal continence after this procedure. DISCUSSION
The principal goals in the treatment of transsphincteric perianal fistulas are eradication of the fistulas tract and preservation of sphincter function. In patients with a fistula, passing through the lower third of the external anal sphincter, these objectives can be achieved by either laying open or excising the fistulas tract. Although these procedures affect anal pressure, the functional results are quite satisfactory. The management of fistulas, crossing the external anal sphincter in the middle or upper third, however, remains a difficult surgical challenge. Treatment of these high transsphincteric fistulas by
a traditional laying open technique will lead to an almost complete transsection of the external anal sphincter with wide separation of both ends. Transanal advancement flap repair has been introduced as a sphincter-preserving alternative. Those who advocate the use of transanal mucosal advancement flap repair argue that this procedure ensures obliteration of the internal opening and thereby healing of the fistula with preservation of the entire external anal sphincter. Initially, quite promising results were reported, with healing rates up to 100 percent, even in patients with Crohn's disease. Recently less favorable results have been reported 6':4 especially in patients who had undergone two or more previous repairs. Furthermore it has been reported that continence deteriorates in quite number of patients after transanal mucosal advancement flap repair. It has been argued that overstretching of the sphincters, caused by the use of a retractor, during the deep intra-anal dissection, contributes to the impairment of continence. In 1996, Del Pino and coworkers introduced the anocutaneous advancement flap repair for the treatment
of transsphincteric fistulas. They reported a small number of patients with promising results. According to these authors, this procedure does not result in anatomic alteration of the anal canal, so all other operative choices are still feasible. In recent years three studies have been conducted to evaluate the role of AAFR in the treatment of high transsphincteric fistula. The reported recurrence rate varied between 5 and 21 percent. Deterioration of continence was observed in only a few patients. Based on these promising results we decided to implement this technique in the treatment of high transsphincteric fistulas. The present study reveals that AAFR is only successful in patients who have undergone no, or only
one previous attempt at repair. The healing rate in this group of patients is similar to the healing rates reported by other workers. The very poor outcome of AAFR in patients who had undergone two or more previous attempts at repair indicates that this procedure is not suitable for this group of patients. In a previous study 6 we found that the outcome of transanal mucosal advancement flap repair is also less favorable in patients who had undergone two or more previous attempts at repair. These data indicate that any flap repair (mucosal or anocutaneous) is less feasible in an area of fibrosis and scar formation caused by earlier anorectal surgery. The relatively high incidence of impairment of continence after AAFR is rather disappointing. Even among patients who had undergone no or only one previous attempts at repair the continence deteriorated in 30 percent of the cases. The procedure was performed without deep intra-anal dissection. Moreover, an exerted anal stretch was kept to a minimum using a special retractor with multiple skin hooks on elastic bands. Therefore it seems unlikely that the impairment of continence is a
result of sphincter damage. It has been postulated by Bielefetdt and coworkers that the sensory- function of the anal canal contributes to the preservation of continence. Disruption of the circumferential continuity of the anoderm and the insertion of less innervated perianal skin into the anal canal might contribute to the deterioration of continence. Surprisingly, five patients, who were incontinent for gas and/or mucus before the procedure, experienced an improvement of their continence status. In two of these patients the fistula healed after AAFR. The other three patients had a drainage seton before the operation, which was removed during the procedure, k might be possible that fistula healing and removal of the setons contribute to the improvement of continence.
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