Advancement sleeve flaps for treatment of severe perianal Crohn's disease

Background Traditionally proctectomy has been the treatment for severe, complex fistula in ano from Crohn’s disease. However, based on the success of rectal advancement flaps in Crohn’s disease, circumferential transanal sleeve advancement flaps (TSAFs) were proposed for this subgroup of patients with severe fistula. Methods From 1991 to 1995, 13 patients (12 women) with severe perianal Crohn’s disease and multiple fistula tracts underwent a TSAF procedure. Data were collected retrospectively using a standard data sheet. Results There were no postoperative deaths or major morbidity. One year after surgery, the fistula had healed in eight of 13 patients (with three requiring additional surgery before healing). Of patients in whom the procedure failed, three underwent proctectomy for progression of disease and the other two had recurrence of a rectovaginal fistula 6 and 8 months after surgery. Of six variables evaluated (previous procedure, steroid use, steroid dosage, associated Crohn’s disease, associated procedures and diverting stoma), only associated procedures were significantly related to a successful outcome (P � 0·008). Conclusion Some patients with severe perianal Crohn’s fistula and a relatively normal rectum can be offered TSAFs. Even with successful outcome in eight of 13 patients, this may still be a viable option if the only alternative would be total proctocolectomy and a permanent stoma. The management of perianal fistulas associated with Crohn’s disease is often challenging and should be tailored to the specific patient. The surgical treatment of these perianal manifestations is based on the location and complexity of the fistula, the presence or absence of concomitant proctitis, sphincteric competence and the severity of accompanying anal canal disease 1 . Patients with symptomatic low-lying simple fistulas involving minimum sphincter musculature without concomitant proctitis can be treated appropriately by fistulotomy 2‐4 . Where faecal continence could be compromised by partial sphincter division in patients with trans-sphincteric or anovaginal fistulas, advancement of partial-thickness flaps has been proposed as the treatment of choice in selected patients with a normal rectum 5,6 . However, extensive ulceration or stricturing of the anal canal and transitional zone is a contraindication for the endoanal sliding advancement flap technique. Definitive treatment of severe perianal Crohn’s disease, including complex fistula in ano and rectovaginal and rectourethral fistula, has traditionally been proctectomy 7‐9 . The technique of rectal sleeve advancement was described by Berman 10 in a woman with combined rectovaginal and cryptogenetic fistulas involving more than one-third of the anal circumference. Since 1991 the authors have used a similar technique for selected complex perianal fistulas resulting from Crohn’s disease. The purpose of this study was to examine the outcome after a transanal sleeve advancement flap (TSAF) procedure in a subgroup of patients with severe and symptomatic perianal Crohn’s disease. The primary endpoint was the success rate, which was defined as healing of the fistulas and ulcers 1 year following surgery.