Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
336 D. D. E. Zimmerman
7.8 Position
Few aspects of advancement flap repair are able to stir up more disputeand debate than
the optimal position of the patient during the operation. Even though many surgeons
from the United States (Ozuner et al. 1996; Golub et al. 1997)aswellasfromEurope
(Schouten et al. 1999)havefiercely propagated the benefits of operating patients in the
prone position, very large series (Boenicke et al. 2017; Bessi et al. 2019; Khafagy et al.
2010;Schwandner2011) have been described in which all patients were operated in
lithotomy (or Lloyd-Davies) position. Obviously, surgeon’s preference (Bondi et al.
2017), or preference of the team or anesthesiologist may also play an important role in
selecting the patient’s position. An intelligent approach that is adopted by many
surgeons is to operate patients with an internal opening on the anterior side in prone
position, while lithotomy is to be preferred in patients in whom the internal opening is
localized posteriorly (Jarrar and Church 2011; Uribe Quintana et al. 2009; Ortiz and
Marzo 2000). Applying this strategy offers the most comfortable approach for creating
an adequate advancement flap and seems to be a logical approach.
8 Aspects of Surgical Technique
Many different modifications have been described by different authors. Several clear
video vignettes are available (Samalavicius et al. 2020; Uribe Quintana 2021). The
technique we use (Zimmerman 2019) has also been described in detail in this
manner. Below a stepwise, detailed description of the technique we use is offered.
8.1 Preoperative Care
All our patients undergo preoperative imaging using detailed MRI. Preoperative
enema is applied before the operation. We operate patients under locoregional or
general anesthesia, depending on patient and/or anesthesiologists’ preference. Preoperative antibiotic (single shot) prophylaxis is administered at the commencement
of the operation. Patient is positioned in Lloyd-Davies position in patients in whom
the internal opening of the fistula is located posteriorly and prone in patients in
whom the internal opening is located anteriorly. We use a pseudo-sterile exposition.
8.2 Step 1
Using a microneedle cautery device, the fistula is cored out (Fig. 1a, b). When
minimal inflammation or very short tracts are present (i.e., anteriorly in women), the
tract is only curetted with a strip of gauze swab. The core-out is extended to at least
the outer edge of the external sphincter. If the intersphincteric space can be reached,
21 Transanal Advancement Flap Repair 337
Fig. 1 (a) Elliptical flap incision, (b) rhomboid flap incision. Red line depicts incision, and red
shaded area depicts submucosal dissection limits
this is preferable. A swab is left in the external defect for hemostasis during the
operation; however, it is removed at the time of closure of the internal opening as it is
likely to be included in the sutures otherwise.
8.3 Step 2
The operation is then continued intra-anally. For exposure, a circular “Scott” type
retractor (using multiple hooks) is used. If exposure is insufficient, a disposable
plastic anal retractor is used, the smallest possible size is selected for this. We
refrain from the use of “Parks” type retractors in all cases due to damage to the
continence mechanism after the use of this contraption (Zimmerman et al. 2003a).
The internal opening is then excised. Any remaining suppuration in the
intersphincteric space or in undrained cavities demonstrated by preoperative
MRI are then excised or curetted (Fig. 2). A small area of epithelium caudally to
the internal opening is excised in order to create a deepithelialized landing zone for
fixation of the flap, to provide sufficient coverage of the former internal opening.
Usually, these actions result in a relatively large defect; however, ideally, only
healthy tissue remains.
8.4 Step 3
A thick rhomboid flap is then created. We aim for a thick flap, incorporating circular
muscle fibers (Fig. 3). Cephalad dissection is continued until a large flap can be
sutured over the internal opening without tension. Usually this means a flap of about
5 cm is created. We use a harmonic scalpel for the creation of the flap; however, we
338 D. D. E. Zimmerman
Fig. 2 (a) Wide angular
rhomboid flap, (b) narrow
round rhomboid flap, (c) wide
round rhomboid flap. Red line
depicts incision, and red
shaded area depicts
submucosal dissection limits
Fig. 3 The impact of
augmentative additional
procedures has never shown
to be beneficial. HER
expected healing rate, HR
healing rate, LAFT laserassisted fistula treatment,
LIFT ligation of the
intersphincteric fistula tract
are aware that many surgeons use a cautery device or even create the flap using
scissors after submucosal infiltration with an adrenalin solution. Even though the use
of a harmonic scalpel is by no means mandatory, it offers a quick dissection and
excellent hemostasis.
21 Transanal Advancement Flap Repair 339
Fig. 4 The Rotterdam Data
concerning prior seton
drainage and healing
(Zimmerman 2003; Mitalas
2010; van Onkelen 2014)
8.5 Step 4
After removing the swab from the external defect, the internal opening is closed,
using individually knotted slow resorbable sutures (Fig. 4). Usually 3–5 sutures are
necessary. Care is taken that no dead space remains.
8.6 Step 5
The flap is then advanced (Fig. 5a) and sutured over (Fig. 5b) the (closed) internal
opening. We use two barbed sutures for this, incrementally increasing tension on the
flap, resulting in a tension-free fixation of the tip of the flap to the neo-dentate line in
most (but not all!) cases. Interrupted slow resorbable sutures are also frequently used
by other authors.
8.7 Postoperative Care
No immobilization, bowel confinement, or postoperative antibiotics are applied. All
patients are released from hospital the morning after their operation (this arbitrary
moment is chosen because many patients in our referral practice have to travel home
after the operation). Patients are instructed to rinse the external wound in their own
shower twice daily, and additionally after a bowel movement. No special wound care
is prescr ibed, and no home care is necessary. Packing of the external wound is
unnecessary and painful and traumatic for the patient.
340 D. D. E. Zimmerman
Fig. 5 (a) Step 5. Advancing the advancement flap, (b) suturing the advancement flap
8.8 Types of Flap
The original description of the technique (as described both by Elting as well as
Aguilar) encompasses the creation of an elliptical (or even straight?) flap as opposed
by more recent authors (Elting 1912; Aguilar et al. 1985), who created a more
rhomboid flap. The main d ifference between these techniques is the vertical incisions
on the lateral sides of the flap (Fig. 1).
As of yet, no authors have described why they choose their different types of flap
design. Most likely training or trainers may play a role in this. Not all authors have
described their exact choice of flap type, and therefore, it is impossible to draw any
meaningful conclusions into the benefitofoneflap type over the other. Moreover, it
is unlikely that in retrospective series (which most are), a fully uniform flap design
was used in all cases. Yellinek and coworkers performed an interesting study in
which they compared the results of a heterogeneous group of fistula repairs (including many different types and etiologies of fistulas) by a rather large group of six
colorectal surgeons who infrequently perform advancement flap repair (about two
procedures per surgeon per year) (Yellinek et al. 2019). They compared patients in
whom a rhomboid flap type was created with patients in whom an elliptical flap type
was chosen. They concluded that there were no differences in healing between these
two groups of patients. On theoretical grounds, it could be advocated that elliptical
flaps will allow better blood supply to the tip of the flap due to the absence of corners
(Yellinek et al. 2019); however, literature does not sufficiently support this belief,
and therefore, we recommend not choosing the type of flap on the grounds of
expected improved healing. In our experience, when a relatively large part of the
distal end of the flap has to be excised (due to suppuration), a rhomboid flap is
usually indicated, in order to achieve a tension free closure.
21 Transanal Advancement Flap Repair 341
8.9 Shape of Flap
Throughout the past 20 years, many different shapes have been described. Wide
angular flaps have been described (Fig. 2a) (Schouten et al. 1999), relatively narrow
round flaps have been described (Fig. 2b) (Willis et al. 2000), and relatively wide
round flaps have been described (Fig. 2c) (Hyman 1999). It is rare for authors to
describe the reason for their choice of flap shape. Moreover, most often flap shape
has to be deduced from schematic drawings, supplied with the article. It is therefore
impossible to draw meaningful conclusions about the preferred shape of the flap.
8.10 Thickness of Flap
More solid research has been done into the optimal thickness of the flap. Different
methods have been described through time varying from the creation of pure
mucosal flaps to utilization of full thickness rectal wall. Both prospective as well
as retrospective investigations have been performed. The difference in approac h was
identified first by the group of Dubsky (Dubsky et al. 2008). Their retrospective
review suggested an improvement of healing rates without higher rates of impaired
continence after full mobilization of the rectal wall. Khafagy and coworkers
performed a prospective analysis, randomizing between flap designs comprising of
mucosa and submucosa with (Group I) or without (Group II) inclusion of circular
muscle fibers (Khafagy et al. 2010). They noticed a statistically significant difference
in recurrence between these two groups in favor of the full thickness flap. The
healing rate of Group I was 90%, whereas a mere 60% healed in Group II. Even
though there was a minor difference in impairment of continence (0% vs. 10%) in
favor of Group II, this difference did not reach statistical significance. Balciscueta
and coworkers investigated this matter by performing a systematic review and metaanalysis (Balciscueta et al. 2017). This group meticulously investigated reports on
full and partial thickness flaps and their influence on healing and fecal continence.
They identified not two but three types of flaps: mucosal, partial thickness, and full
thickness flaps. Some criticism on this classification is warranted in our opinion,
since many reports do not offer detailed descriptions of their technique. Moreover,
most reports are retrospective and many describe operations by different surgeons,
making full standardization of technique unlikely. Nonetheless, this systematic
review elegantly shows an explicit suggestion that there is a strong correlation
between the increasing thicknesses of the flap and improved healing rates. It is
noteworthy that they also showed a higher rate of continence impairment after the
use of thicker flaps, even though statistical significance was not reached. Intuitively,
it is easy to accept that thicker flaps may both lead to high healing rates as well as
poorer continence. It is, however, not entirely clear why the effect on continence
342 D. D. E. Zimmerman
occurs. Khafagy performed anorectal manometry and did not identify differences
between the impact of the two techniques on resting or squeeze pressure (Khafagy
et al. 2010). It is likely that all intra-anal surgery will have an impact on anorectal
continence, however minor it may be. As stated before, selective use of retractors
may play a role. Also some surgeons advocate the type of anesthesia (resulting in
different levels of pelvic relaxation) may play a role. No objective data into this
matter are available. Sensibility of the anal verge may be impaired after creation of
advancement flap, possibly deteriorating fecal continence in some patients. More
extensive dissection when creating thicker flaps may contribute to this. In conclusion, it seems clear that creating advancement flaps that encompass circular fibers, or
even the full thickness of the rectal wall will lead to higher healing rates, at the cost
of a seemingly higher rate of continence impairment. We advocate the use of thicker
flaps where possible, meanwhile recognizing the fact that individualized flap design,
based on the pathology and anatomy of the patient is mandatory.
8.11 Addition of Accessory Techniques
An interesting phenomenon that is observed in many different types of fistula
surgery is the desire of individual authors to combine different treatment modalities
in order to improve the results of said treatment. Regrettably, these additions dilute
the available data on operative techniques, often before their exact role is clarified.
Moreover, authors often attempt to improve their own imperfect results when
compared to initial reports without reporting the initial imperfect result, thereby
inadvertently deflating the publicly available results.
Ellis published a small series of 60 patients undergoing anocutaneous or mucosal
advancement flap repair; in half of these patients, an attempt was made to improve
the results by adding obliteration of the external tract with fibrin glue (Ellis and Clark
2006). A contrary effect was noted. The authors conclude that the study fails to
improve outcome but interestingly does not consider that obliteration of the tract
with fibrin glue may also have a negative effect. Interestingly, not only are the results
of the flap repair poorer than may be expected, the healing rates are also far worse
than those initially published for fibrin glue treatment (between 75% and 81%)
(Cintron et al. 1999; Sentovich 2001). Other authors have also attempted to augment
results of flap repair by obliterating the external fistula tract. Several authors reported
on small series of combined treatment of advancement flap repair and fistula plugs
(Sugrue et al. 2017; Borreman et al. 2014; Mitalas et al. 2010), yielding varying
results (healing rates varying between 25% and 75%). These results are
unimpressive when compared to series reporting on outcome of plug alone
(Gottgens et al. 2015). An attempt to augment results of flap repair by obliterating
the external fistula tract using BioGlue
a pilot study, noticing adverse events (severe pain and/or abscess formation) in seven
patients. Wilhelm and coworkers published their large series of patients undergoing
treatment using laser-assisted fistula treatment (LAFT) (Wilhelm et al. 2017). Fiftythree patients underwent LAFT in combination with mucosal advancement flap
repair. Primary healing was obtained in 35 patients (67%). This healing rate does
®
was aborted after including eight patients in
21 Transanal Advancement Flap Repair 343
not seem to differ from the reported healing rate Giamu ndo and coworkers report
after LAFT alone (without the addition of a flap repair) (Giamundo et a l. 2015;
Stijns et al. 2017). Finally, it was also attempted to augment results of flap repair
by additional ligation of the intersphincteric fistula tract (LIFT). Van Onkelen
and coworkers disappointingly described that, of the 41 p atients, healing was
observed in only 21 patients (51%) (van Onkelen et al. 2012). Again, this
healing rate is lo wer tha n what may be expected of advancement flap repair as
well as what has been reported in studies on LIFT alone (for which a pooled
healing rate of 71% was reported) (Yassin et al. 2013). In conclusion, we notice
that to date, no additional treatment to advancement fl ap repair has ever shown
improved results, both when compared to the expected results of advancement
flap repair as well as to the expected results of the augmentative procedure. In
our opinion, attempts at augmenting the well-investigated and predictable
results of advancement flap repair should be un dertaken with extreme caution
and should only be attempted when a very solid theoretical basis for the
expected improvement of outcomes can be fo rmulated. Furthermore, these
attempts should be considered experimental and can only be undertaken within
studies, after careful and detailed patient inf ormed consent a nd shared decisio nmaking where applicable.
9 Necessity of Preoperative Imaging
The impact of preoperative imaging on the outcome of advancement fl ap repair has
never been investigated. However, the impact of this operation should not be
underestimated. Not only is the healing rate of simple fistulotomy higher, duration
of surgery, length of stay, extent of the wound, and postoperative bother to the
patient are all lower than that of advancement flap repair. Functional outcome is
likely to be similar for well-selected patients. Therefore, patients with simple fistulas
should be selected beforehand and should be offered simple fistulotomy. Conversely,
patients in whom fistulotomy is not feasible (or “safe”) should be selected for a
sphincter saving procedure. In these patients, advancement flap repair should be
considered a serious option. Proper selection of treatment is only possible after
adequate imaging. Both endoanal ultrasound and MRI can be used. Be aware that
many fistulas are more complex than physical examination would make them seem
(Leenders et al. 202 0). For these reasons, preoperative imaging should be performed,
or at least considered, in all patients.
10 Factors Contributing to Successful Healing
Several studies have investigated what factors contribute to healing or failure of
advancement flap repair (Table 1). Upon reviewing these different factors, it is clear
that there is no consensus on what factors can predict failure. Besides, different
authors have used different definitions and aspects of complexity to describe the
fistulas they treated.
344 D. D. E. Zimmerman
10.1 Fistula-Related Factors
Even though several authors have investigated the influence of horsesh oe extensions
on the recurrence rate, only van Onkelen found a statistically significant negative
influence of the presence of horseshoe extensions (van Onkelen et al. 2014).
Intuitively, one would easily understand this factor to be of influence. However,
other authors have not identified fistula complexity as a negative contributing factor.
Anatomy of the fistula was identified by Uribe and coworkers as a negative predictor.
They found a lower healing rate in suprasphincteric fistulas (Uribe et al. 2020);
interestingly, the presence of horseshoe extensions was, however, not identified as a
negative predictor in this same study.
10.2 Patient-Related Factors
Several patient-related aspects are clearly not negative predictors. Several authors
have investigated the influence of patient gender, age, prior seton drainage, alcohol
consumption, and diabetes showing no association with negative outcome (van
Onkelen et al. 2014; Mizrahi et al. 2002; van Koperen et al. 2008; Boenicke et al.
2017; Bessi et al. 2019; Schwandner 2011; Zimmerman et al. 2003b; Uribe et al.
2020; Ellis and Clark 2007). Even though most available evidence therefore suggests
these factors do not play a role, recently Uribe and coworkers were the first to
suggest that the age of the patient has a negative impact on outcome, finding a lower
haling rate in patients over 50. Several factors are matter for debate however. Firstly,
smoking has been identified as a negative predictive factor (Zimmerman et al.
2003b). This finding was confirmed in several other large series (Uribe et al. 2020;
Ellis and Clark 2007). Moreover, a decreased blood flow using laser Doppler
flowmetry was shown in advancement flap repair in patients who smoke cigarettes
(Zimmerman et al. 2005). However, this factor was extensively investigated by
several other authors who did not identify smoking as a negative predictor. Interestingly, a repeat study by the Rotterdam group also did not find a significant difference
between patients who smoked cigarettes and those who did not. It is unclear why this
difference occurred. Possibly patient counseling (concerning smoking cessation)
after the initial publication played a role. A similar debate exists around obesity.
Obesity was identified as an independent negative predictor of outcome by two
research groups (Table 1) (Boenicke et al. 2017; Schwandner 2011) but was
discredited as such by others (van Onkelen et al. 2014; Bessi et al. 2019; Uribe
et al. 2020; Zimmerman et al. 2005). In our opinion, advancement flap repair can be
considerably more challenging in obese patients, so there may definitely be a
rationale behind this factor. Unfortunately, due to the conflicting evidence as well
as the difficulty of intervening, this factor does not seem to be a worthwhile
modifiable factor. In conclu sion, after extensive research over the past 15 years, no
undisputed realistically modifiable factors seem to exist. The one possible exception
is the smoking behavior of the patient. Even though the value of this negative
predictive factor is debated, a dose-response relation was shown, and a
21 Transanal Advancement Flap Repair 345
Supra- versus transsphincteric
e
Contributing factor
No No No No No
c
No Yes ? ? ? ?
a
2003 105 No No No No No Yes No ? No
b
2014 252 No No No Yes
b
No Yes ? No No
>Two fistula drainages,
d
e
No No No No No Yes
No ? No ? ? No
Horseshoe extension,
c
a
d
Same research group, different time span,
b
Table 1 Results of investigations by different authors into the value of different contributing factors
Author Year N Age Gender Prior surgery Fistula complexity Prior seton Smoking Alcohol Diabetes Obesity
Sonoda 2002 48 No ? Yes
Mizrahi 2002 41 No No No ? ? ? ? ? ?
Zimmerman
Schwandner 2011 220 No ? No No No No ? No Yes
Boenicke 2017 61 No No Yes
van Onkelen
Bessi 2018 53 No No Yes
Uribe 2020 190 Yes No No Yes
Prior abscess drainage,
a
Ellis 2006 95 No No Yes ? ? Yes ? ? ?
van Koperen 2008 54 No No No ? No No ? ? ?