[Endorectal advancement flap-plasty vs. transperineal closure in surgical treatment of rectovaginal fistulas. A prospective long-term study of 88 patients].

UNLABELLED

A prospective study was carried out on 88 patients with rectovaginal fistulae to evaluate the value of two sphincter-saving techniques: primary occlusion of the intraanal ostium and endorectal advancement flap (n = 37) or transperineal repair with levator interposition (n = 34). Causes were Crohn's disease 35, obstetric injury 31, proctological-gynecological operation 11, cryptoglandular 11. Perineal group: 11 patients underwent concomitant anterior sphincter plication. Crohn group (n = 35): endorectal advancement flap was performed in 8 patients only, and 10 with intra- or supraanal stenosis were treated by transperineal approach, 12 (34%) with extended perianal fistula complaints required primary proctectomy, and operative therapy was not possible in 5 with persistent rectal inflammation. No deaths occurred. Postoperatively 12 cases (17%) of suture leakage occurred (flap group (FG): 16.2%, transperineal group (TPG): 17.6%). Persistent or recurrent fistula occurred in 8 patients (11%), 5.4% FG, 17.6% TPG. Disturbance of continence was observed in one patient after endorectal approach. Postoperatively there were no significant changes in the resting anal pressure and maximum voluntary contraction pressure. A complete primary healing with no further recurrence (follow-up 3 months to 9.5 years) was noted in 78.4% FG and 64.7% TPG. One patient with postoperative incontinence after the endorectal flap, had undergone anterior levator plication with perineal body reconstruction.

CONCLUSIONS

Endorectal advancement flap allows preservation of the sphincter and is an effective method for repair of rectovaginal fistulae. The endorectal advancement flap proved to result in a better primary healing rate with 85% than the mucosal advancement flap with 65%. Perineal procedures are indicated in selected patients with simultaneous sphincter plication and in Crohn's fistulae associated to intra- or supraanal stenosis.