Anal Sphincter Reconstruction After High Recurrent Anorectal Fistula Excision
Condition: Anorectal Fistula
MeSH terms: Rectal Fistula; Fistula
Study type: Observational

Summary: 
      A retrospective analysis of patients treated for recurrent posterior anorectal fistula, who
      previously had undergone radical excision of fistula-in-ano, was performed. Three types of
      surgical reconstruction were compared: fistulectomy with primary sphincteroplasty,
      muco-muscular advancement flap and full-thickness low rectum posterior semicircular
      mobilization.
    

Detailed description: 
      Radical surgical treatment of anorectal fistulas implies removal of the tract, which ideally
      should be followed by complete wound healing and good anal sphincter function. A big variety
      of techniques to restore the anal canal after fistula excision have been developed, however,
      none of them demonstrates excellent results in difficult clinical situations. Treatment of
      high anorectal fistulas, as well as recurrent fistulas, has always been the most challenging
      task even for expert colorectal surgeons, considering the need to safely restore the anal
      sphincters after surgical trauma in the presence of severe postoperative fibrosis and
      inflammatory changes.

      In high recurrent anorectal fistulas, fistulotomy isn't a method of choice as division of a
      big portion of anal sphincter muscles leads to postoperative incontinence. Muco-muscular
      advancement flap is an accepted technique for the treatment of high transsphincteric
      fistulas, showing the best efficacy in unchanged anal canal. Whereas in recurrent disease,
      due to severe fibrotic deformation of the anal canal, creating an advancement flap can be
      technically difficult and lead to a complication high rate and postoperative incontinence.

      Creation and safe fixation of an endorectal advancement flap (ERAF) in the setting of
      postoperative fibrosis and perifistular inflammation can be technically difficult. Thus,
      mobilizing a full-thickness flap is preferred.

      After coring out a high transsphincteric or suprasphincteric fistula, the wound from the
      inside of the anal canal is located close to the anorectal junction, where internal and
      external anal sphincter fuse with the levator ani muscles. When a full-thickness ERAF is
      created in this situation, first the surgeon enters the intersphincteric plane, and upward
      dissection brings him straight to the supralevator space.

      This maneuver has much in common with mobilising the distal part of rectum as a part of
      intersphincteric resections or transanal mesorectal excision for rectal cancer [35] , [36] .
      After the upper part of the rectum has been mobilized, a surgeon from the perineal team makes
      a circular incision of the anal canal above the dentate line, enters the intersphincteric
      space and continues dissection in cranial direction following the surface of the mesorectal
      fascia, thus separating the lower part of mesorectum from the levator ani muscles.

      Being an expert in intersphincteric resections, the leading surgeon utilized this approach in
      three patients after excision of a high recurrent anal fistula. Sphincteroplasty and standard
      ERAF creation were not possible due to severe fibrosis, so mobilizing the posterior
      semicircle of the rectum the same way as in intersphincteric rectal resection was deemed to
      be the last resort in order to close the wound. In fact, a wide well-vascularized posterior
      ERAF was created. The upward dissection was continued until the Waldeyer's septum was reached
      and divided to ensure tension-free fixation of the flap in the anal canal.
    

Intervention name(s): fistula tract excision and anal sphincter reconstruction
Intervention type(s): Procedure
Intervention description(s): The primary fistulous tract was excised together with any secondary tracts or residual cavities. Then on of the reconstructive steps was performed
Observational model: Cohort
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Men and women with high recurrent posteriorly located anorectal fistulas