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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1056_Библиотеки_им_академика_М_И_Перельмана.pdf
356 R. Nelson et al.
Fig. 4 House flap. (From
Sentovich et al. (1996) with
permission)
opening. If the fistula recurs, several options exist, from a long-standing seton to
fistulotomy. In addition, it is possible to redo the flap. This second operation is often
easier than the initial one. It invol ves cutting on a road map left by the scar line of the
previous incision. Mobility is not diminished. In some Crohn’s patients the internal
opening of the fistula has been found to be too large and friable to attempt closure at
that level. In those cases the fistula was only covered by the flap with no closure of
the internal opening, and they have healed. (So is closing of the internal opening
necessary?)
3 Other Dermal Flaps
Shown are drawings of other dermal flap procedures that have been used to treat anal
fistula including rectovaginal fistulas in patients with and without in flammatory
bowel disease (IBD) (Figs. 3, 4, 5, 6, 7, and 8). The variations in technique and
22 Dermal Flap Anoplasty for Trans-sphincteric Anal Fistula 357
Fig. 5 VY flap. (From Robertson and Mangione (1998) with permission)
results of the operations are found in Table 1 (Jun and Choi 1999; Nelson et al. 2000;
Zimmerman et al. 2001; Amin et al. 2003; Robertson and Mangione 1998;
Sungurtekin et al. 2004; Sentovich et al. 1996; Hossack et al. 2005; Alver et al.
358 R. Nelson et al.
Fig. 6 Diamond flap. (From
Hossack et al. (2005) with
permission)
2008; Pescatori et al. 1995; Ertem et al. 2014; Hesterberg et al. 1993; Koehler et al.
2004). These were all small case series. One randomized controlled trial has been
performed (Ho and Ho 2005 ). It is a very small study which compared island flap
anoplasty to usual fistula treatment which was mostly fistulotomy, though a few
patients only received a seton. There were ten patients in each group, and the
findings were, of course, inconclusive.
The success of dermal flaps varies greatly (Table 1) and is overestimated in small
series, while the figures closest to reality are from the largest studies, that is, the 52%
healing rate in 81 patients undergoing dermal flaps at Cook County Hospital (Sugrue
et al. 2017) and the 72% healing of 72 island flaps by Nelson et al. (2000). In the
comparative series by Sugrue, rectal and dermal flaps had the highest healing rate
among all sphincter-saving procedures (57% and 52% respectively), followed by
22 Dermal Flap Anoplasty for Trans-sphincteric Anal Fistula 359
Fig. 7 Combined mucosa
pedicle and dermal house flap.
(From Ertem et al. (2014))
Fig. 8 House flap construction. (From Zimmerman et al. (2001) with permission). Drawing of the
flap with the base twice as large as the apex (a). The fistula is excised, the internal opening is closed,
and the flap is sutured to the mucosa and anal sphincter (b)
LIFT (47%) (Sugrue et al. 2017). Complications were rare and are limited to wound
breakdown, pain, and itching (Hossack et al. 2005). Worsening of anal continence is
uncommon (Table 1).
The simplest of all the procedures is an advancement flap much like what is done
with mucosal flaps, and it is a pedicled flap (Fig. 3, and (Jun and Choi 1999)) also
used for the treatment of anal fissures (Giordano et al. 2009). The blood supply to the
360 R. Nelson et al.
Anal
incontinence
n.a.
15 cured
52% and worse
in 17%
after
score from 5.2
to 3.2
both patients
with Bowen’s
Lateral
and/or
52 (72%) 17,
procedures # Fistulas cured (%) IBD
# Dermal flap
distal
closure Fistulectomy
65 patients
Island No ¾ Yes 26 12 (46%) 0 Improved in
VY No Yes No 20 16 (80%) 8 5%
VY No Yes Yes 65 59 (90%) 0 13% before and
0 (0%) 0 Incontinence in
House No Yes No 30 flaps in
29 patients
only 1 for
fistula
3 (75%) 0 n.a.
28 patients
but 4 for
fistula
Double flap No Yes n.a. 4 4 (100%) n.a. 0%
Table 1 Table of representative publications of dermal flap closure of anal fistula
Nelson et al. (2000) Island No No No 72 flaps in
Author Flap Pedicle
Zimmerman et al.
(2001)
Amin et al. (2003) VY No ¾ Yes 18 15 (83%) 0 5%
Robertson and
Mangione (1998),
Sentovich et al.
(1996)
Sungurtekin et al.
(2004)
Hossack et al. (2005) Diamond Island No Yes No 16 15 (93%) n.a. St. Mark’s
Sentovich et al.
(1996)
Alver et al. (2008) House No Yes No 36 flaps in
Pescatori et al.
(1995)
22 Dermal Flap Anoplasty for Trans-sphincteric Anal Fistula 361
score of 1
n.a. n.a.
37 (52%) healed
and 10 lost to
follow-up
Double flap
Dermal flap
and 5 double
5 (100%) healed
flap
Ertem et al. (2014) Double flap No Yes Yes 13 13 (100%) 0 Mean Wexner
No No No 10 10 (100%) 10 n.a.
In rectovaginal
fistula,
Dermal YV flap.
Stoma in most
Hesterberg et al.
(1993)
No Yes Yes 42 37 0 n.a.
cases
Koehler et al. (2004) YV or combined
2 flap
In very distal
fistulas
Jun and Choi (1999) YV pedicle flap Yes Yes Yes 40 38 n.a. 0%
n.a. n.a. n.a. 81 dermal flap
Sugrue et al. (2017) Unknown type
of dermal flap
and double flaps
IBD inflammatory bowel disease, n.a. not available
362 R. Nelson et al.
flap comes exclusively from the pedicle. It was to gain greater mobility of the flap
and to reach more proximal fistulas that these other techniques were developed. In
the table there are procedures that have other major differences in technique to the
operation described above. Most flaps in Table 1 are islands, that is, they depend on
blood supply to the flap (Nelson et al. 2000; Zimmerman et al. 2001; Amin et al.
2003; Robertson and Mangione 1998; Sungurtekin et al. 2004; Sentovich et al. 1996;
Hossack et al. 2005; Alver et al. 2008; Hesterberg et al. 1993) arising from beneath
the flap and not coming from a pedicle (Jun and Choi 1999; Pescatori et al. 1995;
Hesterberg et al. 1993), and the skin incision is circumferential. All but Nelson’s
island flap (Nelson et al. 2000) and the house flap described by Zimmerman et al.
(2001) in Fig. 8 closed skin distal to the dentate line, which we felt would increase
pain and outward tension. About half did fistulectomy of the track underlying the
dermal flap (Jun and Choi 1999; Zimmerman et al. 2001; Amin et al. 2003;
Sungurtekin et al. 2004; Ertem et al. 2014; Koehler et al. 2004). Inclusion of the
external opening and of the whole tract in the flap depends on the position and
distance of the external opening with respect to the internal opening and is not
essential.
4 Discussion
For anal fistula, dermal flap differs from mucosal flap procedures in several important aspects. The first is that there has been a good deal more research published
related to mucosal flaps including randomized trials (Bondi et al. 2017) and metaanalyses (Balciscueta et al. 2017) of randomized trials. In order to do a mucosal flap
covering of a cryptoglandular fistula, a mucosal ectropion must be created, positioning the distal mucosa flap edge distal to the dentate line. This can cause moisture and
leakage. In addition the mucosal advancement flap is often quite difficult to perform,
especially in the presence of Crohn’s disease or ulcerative colitis (IBD). Finally a
mucosal flap would never be done in somebody with an active Crohn’s proctitis.
When the dermal island flap is used for fistula, it differs from the Hooks operation
(Pearl et al. 1990) in most cases in that the fistula itself goes beneath the flap from the
internal opening in the rectum to the externa l opening in the perianal skin. It is not
intuitive that this should work. Our first case of island flap anoplasty was on a young
woman with Crohn’s disease and active proctitis with symptomatic fistula. In 1994,
there were no conceivable alternatives. If it had not worked, we probably would not
have tried it again.
Because of the very paltry data for dermal flap, no recommendation can be made
whether dermal flap anoplasty is to be preferred over mucosal flap or ligation of
intersphincteric fistula tract (LIFT). Dermal flaps are safe and have a success rate
similar to mucosal flap and LIFT. Together with LIFT they are feasible in patients
with active proctitis. The reported complication rate is low, but data on the incidence
of incontinence in island flaps are vague and need to be better investigated. Dermal
flaps, whether for fistulas, ectropion, fissure, or stenosis, are an essential part of the
colorectal surgeon’s armamentarium.
22 Dermal Flap Anoplasty for Trans-sphincteric Anal Fistula 363
5 Cross-References
▶ Transanal Advancement Flap Repair
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advancement flap in anorectal diseases. World J Surg 32(10):2281–2286. https://doi.org/
10.1007/s00268-008-9699-1. PMID: 18679744
Amin SN, Tierney GM, Lund JN, Armitage NC (2003) V-Y advancement flap for treatment of
fistula-in-ano. Dis Colon Rectum 46(4):540–543. https://doi.org/10.1007/s10350-004-6596-
z. PMID: 12682551
Balciscueta Z, Uribe N, Balciscueta I, Andreu-Ballester JC, García-Granero E (2017) Rectal
advancement flap for the treatment of complex cryptoglandular anal fistulas: a systematic review
and meta-analysis. Int J Color Dis 32(5):599–609. https://doi.org/10.1007/s00384-017-2779-7.
Epub 2017 Feb 28. PMID: 28247060
Bondi J, Avdagic J, Karlbom U, Hallböök O, Kalman D, Šaltytė Benth J, Naimy N, Øresland T
(2017) Randomized clinical trial comparing collagen plug and advancement flap for trans-
sphincteric anal fistula. Br J Surg 104(9):1160–1166. https://doi.org/10.1002/bjs.10549. Epub
2017 May 10. PMID: 28489253
Ertem M, Gok H, Ozveri E, Ozben V (2014) Application of advancement flap after loose seton
placement: a modified two-stage surgical repair of a transsphincteric anal fistula. Ann
Coloproctol 30(4):192–196. https://doi.org/10.3393/ac.2014.30.4.192. Epub 2014 Aug
26. PMID: 25210689; PMCID: PMC4155139
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resistant chronic anal fissure: a prospective study. World J Surg 33(5):1058–1063. https://doi.
org/10.1007/s00268-009-9937-1
Hesterberg R, Schmidt WU, Müller F, Röher HD (1993) Treatment of anovaginal fistulas with an
anocutaneous flap in patients with Crohn’s disease. Int J Color Dis 8(1):51–54. https://doi.org/
10.1007/BF00341278. PMID: 8492045
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sphincteric fistula-in-ano: early results. Tech Coloproctol 9(2):166–168. https://doi.org/
10.1007/s10151-005-0220-7. Epub 2005 Jul 8. PMID: 160073
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2004.00745.x. PMID: 15720361
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(4):490–492. https://doi.org/10.1046/j.1365-2168.1999.01077.x. PMID: 10215820
Koehler A, Risse-Schaaf A, Athanasiadis S (2004) Treatment for horseshoe fistulas- in-ano with
primary closure of the internal fistula opening: a clinical and manometric study. Dis Colon
Rectum 47(11):1874–1882. https://doi.org/10.1007/s10350-004-0650-8. PMID: 15622580
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10.1007/BF02235588. PMID: 10826431
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19–21. https://doi.org/10.1007/BF00337580
ap repair for complex and recurrent
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10.1007/BF02234601. PMID: 11598477
(LIFT) Ligation of Intersphincteric Fistula Tract
Ibrahim Ethem Gecim
Abstract
For the fistuli that we cannot do fistulotom y, there were several surgical tech-
niques described. Ligation of the intersphincteric fistula tract is one of these
methods especially for low-laid trans-sphincteric fistuli in low BMI patients. In
this chapter, the technique and results of LIFT procedure are discussed.
There are several fistula classifications, but in my practice, perianal fistulas can be
divided into two types: the fistulas we can perform a fistulotomy, and the ones we
cannot. Basically, we define the fistulas that we cannot perform fistulotomy as
“complex fistulas.” If the fistula
23
• Tract comprises 30–50% of the external sphincter
• Is located in the anterior half (especially in women)
• Has multiple tracts
• Is a recurrent one and if the patient
• Has preexisting incontinence
• Has had local irradiation
• Has Crohn’s disease
then the term “complex fistula” might be convenient, and in my own terms, these are
the ones that we cannot perform a fistulotomy (Steele et al. 2011).
In some cases, “do” or “don’tdo” fistulotomy may not be as clear as red and
green. I and my colleagues take the puborectal ring as a the red line. In most cases, I
perform fistulotomy for the ones which are distal to puborectal muscle. Depending
on the experience, even if the fistula is distal to puborectal ring, some cases with
I. E. Gecim (*)
Colorectal Unit, Ankara University Medical School, Ankara, Turkey
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_25
365