Surgical treatment of high anorectal and rectovaginal fistulas with the use of transanal endorectal advancement flaps

Background: Sphincterotomy can be avoided in the repair of high anorectal or rectovaginal fistulas by use of rectal advancement flaps.

Methods: Between 1986 and 1998, 22 patients with high anorectal and 15 patients with rectovaginal fistulas underwent fistulectomy without sphincterotomy and consecutive transanal rectal advancement flap repair.

Results: Primary healing was achieved in 81% (30/37 patients). There was no disturbance of continence though anal resting pressures decreased postoperatively. Recurrences occurred in 4 of 12 patients with Crohn's disease (2 anorectal, 2 rectovaginal) and in 1 patient with traumatic anorectal fistula. There were no recurrences in patients with cryptoglandular disease, while the operation failed in 2 patients with ergotamine-induced fistulas.

Conclusions: This operative approach achieves a high primary healing rate with optimal functional outcome. Despite good results the indication should be set carefully in patients with Crohn's disease.