Transcript Advancement flaps

Advancement flaps for fistula in
ano
SR Brown
Sheffield teaching hospitals
Perfect operation
• Easy to perform
• No risk of incontinence
• Effective
History
• First proposed 1902 (Noble) for
rectovaginal fistulae
• Anal fistulae 1912 (Elting)
Objectives
• Indications
• Types and Techniques
• Results
Indications
• High trans-sphincteric/supra-sphincteric
fistulae
• Anterior fistulae in women
• Rectovaginal fistulae
• (Crohn’s)
Contraindications
• Acute presentation
• Large opening
• Rectal disease
– Neoplasia
– Crohn’s
– Radiation
Types of advancement flap
• Endorectal
– Full thickness
– Partial thickness
– mucosal
• Anocutaneous
– V-Y,Y-V
– Rhomboid, House
Method
• Bowel preparation
• Antibiotics
• Position
Essential steps
•
•
•
•
Excision of internal opening
Excision primary tract
Formation flap
Attention to external component
Excision fistula tract
• Sharp dissection core out/curettage
• Excise secondary tracts
• Continue to internal sphincter/complete
tract
Mobilisation rectal flap
• Adrenaline (1:300,000)
• Partial/full thickness internal sphincter flap
(based proximally)
• Divergent lateral incisions
• Meticulous haemostasis
• Excise internal opening +/- closure internal
tract
Suturing flap
• Suture with absorbable Vicryl 2/0
• Tension free
• Leave external opening to drain/Malecot
catheter/glue
• No indication for bowel confinement/stoma
Principles for success
• Stagger the mucosal and muscular suture
line
• Width of base of flap > twice the apex
• No sepsis
Results
Difficulties
• Due to
– Population
• Inflammatory/Non inflammatory
• High/low fistulae
• Recurrent
– Surgeon
– Follow up
– Thoroughness of reporting
Results
Endorectal Technique
Study
Year
No. pts.
Recurrence
(%)
Incontinence
(%)
Oh
1983
15
13
-
Aguilar
1985
151
2
10
Athanasiadas
1994
169
20
21
Schouten
1999
44
25
35
Ortiz
2000
91
7
8
Mizrahi
2002
66
33
9
Sonoda
2002
55
25
-
Dixon
2004
29
17
-
Reasons for Incontinence
•
•
•
•
Direct damage to sphincter
Stretching
Scarring
Decreased sensation
The anocutaneous flap
Results
Anocutaneous technique
Study
Year
No Patients
Recurrence
(%)
Incontinence
(%)
Del Pino
1996
11
27
-
Nelson
2000
73
23
16
Zimmerman
2001
26
54
30
Amin
2003
18
17
-
Sungertekin
2004
65
9
0
Factors that influence healing
•
•
•
•
Redo procedures
Crohn’s
Rectovaginal fistulas
Smoking
Summary
• Advancement flaps useful part of
armamentarium for fistulas
• Techniques equally effective
• Consent for recurrences/incontinence
particularly certain groups
Rectovaginal fistulae
causes
• Inflammatory
– Crohn’s
– Neoplastic
– Post-radiotherapy
• Non inflammatory
– obstetric
Rectovaginal fistulae
types
Types of repair
• Transanal advancement flap
• Lay open and primary repair
(perineoproctotomy)
• Transperineal repair (+/- transposition)
• Transvaginal repair