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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 86 | Outcomes of Primary Repair of Anorectal and Rectovaginal Fistulas Using the Endorectal Advancement Flap [2002년 12월 DCR] | 2011-11-17 | 3730 |
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Toyooki Sonoda, M.D., Tracy Hull, M.D.,Marion R. Piedmonte, M.A., Victor W. Fazio, M.B., M.S.
From the Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
PURPOSE: The endorectal advancement flap is a surgical procedure used in the treatment of anorectal and rectovaginal fistulas. There is a wide range of success rates published in the literature. This study was undertaken to examine the success rate of primary endorectal advancement flap in our own institution. We attempted to identify factors that influence the rate of healing.
METHODS: A retrospective review was performed on 105 patients (43 males) who underwent their first endorectal advancement flap at our institution between January 1, 1994, and June 30, 1999. Ninety-nine
patients were available for follow-up. Sixty-two patients had anorectal and 37 had rectovaginal fistulas. The causes of fistula included cryptoglandular (48 patients), Crohn’s disease (44), obstetric injury (5), trauma (1), and other (1). RESULTS: The median follow-up was 17.1 (range, 0.4–66.9) months. The median age was 42 (range, 16–78) years. Recurrence was seen in 36 patients (36.4 percent); thus, the primary rate of healing was 63.6 percent. Factors that were associated with higher rates of success were increased age (P = 0.011), greater body surface area (P = 0.012), history of incision and drainage of a perianal abscess preceding advancement flap (P = 0.010), previous placement of a seton drain (P = 0.025), and short duration of fistula (P = 0.003). Factors that negatively influenced the healing rate of the flap were the diagnoses of Crohn’s disease (P = 0.027) and rectovaginal fistula (P = 0.002). Length of hospitalization, discharge on oral antibiotics, and the presence of a diverting stoma did not influence the rate of healing. Prednisone was associated with a distinct trend toward failure, with none of the patients on high-dose prednisone (greater than 20 mg/day) having achieved long-term healing. No fistulas recurred after a period of 15 months. CONCLUSION: The endorectal advancement flap is an effective method of repair for both anorectal and rectovaginal fistulas, even though the success rate may not be as optimistic as in some other published studies. Patient selection is imperative, realizing that a higher rate of failure may be present in Crohn’s disease and rectovaginal fistulas. Control of sepsis before endorectal advancement flap with drainage of a perianal abscess and/or seton placement, whenever possible, is indicated.
The description of an anal fistula took place as early as 430 B.C. by Hippocrates. His surgical
management of this condition using a seton remains one of the oldest surgical procedures recorded. Subsequent to this, but still about 600 years ago, the “lay open” technique for perianal fistulas was described by John Arderne. This method, to this day, is successfully used in clinical practice. Unfortunately, this procedure not infrequently leads to the division of healthy sphincter muscle, resulting in varying degrees of fecal incontinence. Many techniques have been developed in the attempt to treat anorectal and rectovaginal fistulas. One
of these methods is the endorectal advancement flap (EAF). This technique was first described as the “sliding flap” in 1902 by Noble and then modified in 1948 by Laird. The goal of this procedure is to obliterate the internal opening of a fistula tract without significant alteration in anal sphincter function. The EAF has been used to treat fistulas of various causes, including cryptoglandular disease, obstetric injury, trauma, and inflammatory bowel disease. It has been successfully used in the treatment of both anorectal and rectovaginal fistulas. There has been a wide range of success rates of the EAF in the literature, ranging from 29 to 95 percent in larger studies. This procedure has been performed at our institution since 1981. In 1996 our institution
reported on the success rate of the transanal rectal advancement flap in 101 patients who underwent surgery between 1988 and 1993. The median follow-up in this study was 31 months, and the overall success rate of the EAF was 71 percent. The rate of failure was higher in patients who had previous attempts at fistula repair, but there were no other variables that seemed to influence the rate of recurrence, including cause of disease (cryptoglandular vs. Crohn’s disease). Other studies have identified factors that adversely affect healing, and these includes Crohn’s disease and type of fistula (specifically, rectovaginal fistula).These findings are not universal throughout the literature, however, and there continues to be uncertainty regarding what kind of success rate can be anticipated for the EAF. Despite the results of our earlier study, we suspected from our clinical experience that specific subsets
of patients have worse outcomes when compared with others, and this prompted us to reevaluate our own experiences with the EAF. This study reexamines the success rate of the EAF in our institution during the past five and one-half years. |
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