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488 D. Morte et al.
a 65% success rate in 23 patients, in which of note, 70% of these patients were
diverted. The most frequent complication is dyspareunia, which is reported in up to
30% of patients by 6 weeks postoperatively, with the next most frequent complication being labial wound issues in <10% (McNevin et al. 2007).
6 Gluteal Muscle Interposition Flap
6.1 History and Indications
Gluteal flaps have been used as local-regional fasciocutaneous flaps for vulvar and
vaginal reconstruction due to their ability to cover large defects. They have the
benefit of having consistent vascular an atomy, reliable vascularity, ability to be
raised in many positions, adequate bulk, minimal sequelae, and well-hidden donor
scars (Pantelides et al. 2013). They have more recently been described for the repair
of rectovaginal fistulas following rectal cancer surgery as a means for providing a
robust flap and tissue pedicle (Kosugi et al. 2005). This is beneficial in pati ents that
have undergone multiple prior repairs for a recurrent rectovaginal fistula and are at a
high risk for recurrence. However, there have been few studies that have reviewed
the clinical features or operative techniques of the use of gluteal fold flaps for the
repair of rectovaginal fistulas.
6.2 Surgical Technique
Kosugi and associates (2005) describe the following technique for perfor ming a
gluteal fold flap repair for a rectovaginal fistula following rectal cancer resection.
Patients typically receive a mechanical bowel preparation and intravenous antibiotics preoperatively. They are placed into the lithotomy position. The vaginal and
rectovaginal fistula openings are identified, and a transvaginal incision is made
around the fistula tract. The edges of the incision are undermined circumferentially
until the external rectal muscular layer is encountered. The fistula is divided and
debrided, and the rectal opening of the fistula is closed using two layers of absorbable sutures in an interrupted horizontal mattress fashion.
The proposed gluteal fold flap is drawn with a skin marker and the flap created
with an incision along the poste rolateral margin of the vaginal introitus. The shape
can be triangular or diamond-shaped and consists of skin, subcutaneous fat, and
superficial fascia. It is important to remember that the blood supply from the internal
pudendal artery reliably runs just medial to the ischial tuberosity, and there may be
several additional perforating vessels (Fig. 12). If the flap appears to have excessive
bulk, it can be thinned without too much concern for compromising the blood supply
(Hashimoto et al. 2001). The flap is turned 180 degrees and advanced into the
29 Additional Surgical Options to Treat Anal Fistulas: Gracilis... 489
Fig. 12 Gluteal flap blood
supply is from the internal
pudendal artery which reliably
runs medial to the ischial
tuberosity. (Reprinted with
permission, Cleveland Clinic
Center for Medical Art &
Photography © 2020. All
Rights Reserved)
vagina. Absorbable interrupted sutures are used to suture the flap to the vagina
mucosa, covering the fistula tract and opening. The gluteal skin defect is closed
primarily (Fig. 13). Drains are routinely placed under the tissue of the flap.
A diverting loop ileostomy or transverse colostomy can be created if it was not
performed preoperatively.
6.3 Results/Complications
While there is a scarcity of data regarding the specific use of gluteal flaps in the repair
of rectovaginal fistulas, it has shown great promise in a small study completed by
Kosugi et al. (2005). They report that in five patients receiving a gluteal flap repair,
there was no relapse of a rectovaginal fistula after greater than 1 year of postoperative monitoring. There were also no complications noted at follow-up. This has
been supported in literature regarding the use of gluteal fold flaps in perianal
reconstruction. Windhofer et al. (2011) reported complete healing in 13/14 patients,
with the only complications encountered being wound dehiscence and partial flap
necrosis. Ragoowansi et al. (2004) reported 86% of patients had complete healing,
11% had partial flap necrosis secondary to excessive skeletonization of the vascular
pedicle, and 3% had complete necrosis requiring split-thickness skin graft
490 D. Morte et al.
Fig. 13 Completed gluteal
flap after 180 degree rotation
to cover perineal/vaginal
defect. (Reprinted with
permission, Cleveland Clinic
Center for Medical Art &
Photography © 2020. All
Rights Reserved)
reconstruction. Only 19% of the flaps retained protective sensation, and 17% of
patients were able to return to sexual activity following reconstruction.
There are several potential limitations regarding the use of gluteal fold flaps. The
first is the underlying disease process can cause compromise to the integrity of the
required skin for the flap, such as in the setting of Crohn’s disease and multiple
perianal fistulas or excessive scarring from multiple prior repairs (Shahzad et al.
2014). The flap also has a limited width of approximately eight centimeters which
may preclude repair of high fistulas. It is also recommended that patients not sit on
the donor site for at least 3 weeks postoperatively which can be difficult for patients
to be compliant with. Nonetheless, the gluteal fold flaps remain a viable option in the
repair of rectovaginal fistulas.
7 Conclusion
Perianal and rectovaginal fistulas are a difficult disease process for both patients and
surgeons alike. They have a wide range of presentation, causes, and treatments with
no well-defined guidelines or algorithms regarding progression of treatment. It is
important to have a comprehensive understanding of the underlying disease process
and available options for effective treatment as they can have major psychological
and significant effects on quality of life from failure or postoperative complications.
29 Additional Surgical Options to Treat Anal Fistulas: Gracilis... 491
Table 1 Summary of success, complications, and recurrences in the three primary flap procedures
for rectovaginal fistula treatment
Success Complications Recurrence Additional
Gracilis
flap
Martius
flap
Gluteal
flap
All procedures at risk of flap failure and infection
83% Thigh
65% Dyspareunia
Limited
data
paresthesia (2%)
(30%)
Buttock
paresthesia
58%
6%
0/5 in small study
(Kosugi)
Sitting precautions
Skin issues related to
disease process
Muscle interposition flaps are an effective and successful intervention when used in
the correct setting and should be considered for patients with recurrent fistulas
(Table 1).
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Quality of Life Following Anal Fistula Treatment
Dieter Hahnloser
Contents
1 Introduction . ............... .................................................................. 496
2 Quality of Life with an Anal Fistula .................................. ...................... 496
2.1 Cryptoglandular Fistulas ................................... ........................... 496
2.2 Crohn’s Anal Fistula ............................. ............................. ........ 497
2.3 Conclusion ............................................................................. 498
3 Quality of Life with a Seton and a Fistula .................................................. 498
3.1 Conclusion ............................................................................. 499
4 Quality of Life After Fistula Treatment ..................................................... 499
4.1 Simple Anal Fistula (Fistulotomy) .................................................... 499
4.2 Anal Fistula Plug . ..... . .................... ........................................... 500
4.3 Advancement Flap .................................................................... 500
4.4 Lift ............................................ ......................................... 501
4.5 Video-Assisted Anal Fistula Treatment (VAAFT) . ................................... 501
4.6 Sexual Function ..... ................................. ................................. 501
4.7 Conclusion ............................................................................. 501
5 Cross-References .......................... ............................................. ..... 502
References ............................ ............................................... ............ 502
30
Abstract
The symptoms most frequently associated with an anal fistula include suppuration, bleeding, and/or pain, which are often preceded by the drainage of a perianal
abscess and seton placement. All can severely affect patient’s quality of life
(QoL). Patients with anal fistula have a reduced QoL, which is worse with
recurrent disease, secondary extensions, and urgency. Setons should be placed
loosely and should be comfortable. Their main goal is to relieve symptoms,
prevent perianal sepsis, and to condition the fistula for reparative surgery. QoL
is improved and continence is not impaired with a seton. Patients undergoing
D. Hahnloser (*)
Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
e-mail: dieter.hahnloser@chuv.ch
© 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_33
495
496 D. Hahnloser
fistula surgery have only a 50–70% chance of cure. They should be counseled
appropriately and warned that multiple interventions may be necessary. Fortunately, major symptoms such as pain and discharge improve and the risk of
incontinence following fistula surgery is low. Patients can expect an improvement
in symptom-specific QoL. Core outcome sets and specific validated QoL questionnaires should be used in the future to compare outcomes.
Keywords
Quality of Life · QoL · Anal fistula · Functional outcome · Urgency ·
Incontionence
1 Introduction
The symptoms most frequently associated with an anal fistula include suppuration,
bleeding, and/or pain, which are often preceded by the drainage of a perianal abscess
and seton placement. All can severely affect patient’s quality of life (QoL). Treatment of anal fistulas can affect fecal continence, which also impairs QoL. In the light
of this, patient’s QoL emerges as an important indicator that should be taken into
consideration when making individualized decisions on the treatment strategy.
“Civilization rests on two things, the discovery that fermentation produces
alcohol, and the voluntary ability to inhibit defecation” (Robertson Davies, The
Rebel Angels, 1981). The biggest fear of fistula treatment is impairment of fecal
continence. Therefore, the goal of any anal fistula treatment must be: first to preserve
fecal continence (and maintain a qood QoL) and secondly to cure the fistula.
“Recurrence is better than total incontinence” (unknown).
In this chapter, three aspects of QoL in anal fistula will be discussed: QoL with an
anal fistula, QoL with a seton, and finally QoL after anal fistula treatment.
2 Quality of Life with an Anal Fistula
2.1 Cryptoglandular Fistulas
A study from the St. Mark’s Clinic in 146 patients (median age of 44 years) with
cryptoglandular fistulas assessed QoL using the St Mark’s Incontinence Score and
the short form-36 Health survey (SF-36) questionnaire at the point of referral (Owen
et al. 2016). In general, QoL worsened with increasing incontinence scores. However, none of the SF-36 domains showed a strong correlation with continence score,
with a fair correlation found between continence score and the Physical Functioning
domain. QoL in recurrent fistula (22% in this study) was significantly worse than in
patients with a primary fistula on two domains of physical and social functioning.
Setons (in 35% of patients) and secondary extensions (22%) had no impact on
continence nor on QoL. Urgency (present in 24% and defined as the inability to
30 Quality of Life Following Anal Fistula Treatment 497
defer defecation for 15 min) correlated with a median continence score of 11, however, was similar in patients with or without a seton or a secondary extension. In
summary, patients with anal fistula had a reduced QoL, which was worse in those
with recurrent disease, secondary extensions, and urgency. However, loose seton had
no impact on QoL.
A Spanish study developed and validated a Quality of Life in Patients with Anal
Fistula Questionnaire (QoLAFQ) (Ferrer-Marquez et al. 2017). This questionnaire
specifically measures quality of life in people with anal fistula from zero impact
(14 points) to very high impact (57–70 points). The questionnaire focuses on
physical aspects on QoL such as discharge, bleeding, noncontrolled flatulence, and
pain, as well as on biopsychosocial aspects such as subjective health perception
(physical and psychological), independence, social relation, sexual life, and attitude.
The same authors prospectively evaluated 80 patients using their QoLAFQ (FerrerMarquez et al. 2018). QoL was significantly worse in recurrent fistulas and in
patients with <6 months of symptoms. Patients with clinical symptoms >6 months
up to 5 years seem to adapt or cope with the situation and impact on QoL is less.
There were no statistically significant differences between QoL among patients
diagnosed with complex or simple fistulae. The QoLAFQ could contribute to the
evaluation of QoL among patients with cryptoglandular anal fistula, however, is not
widely used.
The development of an European cryptoglandular Anal Fistula Core Outcome Set
(AFCOS) is currently being conducted through an international Delphi consensus
(Machielsen et al. 2020).
2.2 Crohn’s Anal Fistula
The impact of perianal fistula(s) on patients with Crohn’s disease is intense and wide
reaching, negatively affecting intimate, close, and social relationships. Fistulas cause
losses in life and work-related opportunities, and treatments can be difficult to
tolerate. Crohn’s perianal fistulas exert a heavy negative physical and emotional
impact on patients. These findings of 12 standardized interviews helped to develop
patient reported outcome measures (PROM) to assess treatment effectiveness and
QoL for patients living with peria nal Crohn’s disease fistula (Adegbola et al. 2020b).
The current literature on perianal Crohn’s fistula is limited by a lack of standardized outcome measures. Several authors proposed a core outcome set (COS)
reflecting the minimum outcomes that should be reported in all trials (Sahnan et al.
2019; Ma et al. 2019). The COS contains patient- and clinician-reported outcomes.
The patient-reported outcomes are:
• Global assessment of quality of life
• Combined score of patient priorities on
– Lifestyle restriction (general)
– Lifestyle restriction based on toileting needs
– Depression
498 D. Hahnloser
– Inability to attend school/work and restriction of sexual activity and avoidance
of intimacy.
• Global assessment of incontinence.
This COS still requires international validation. It is also necessary to develop a
core measurement set, a collection of measurement tools, and standards by which
these outcomes can be assessed in a given study.
In 2020, data from 211 patients contributed to the development of a final 28-item
questionnaire, the Crohn’s Anal Fistula Quality of Life (CAF-QoL) (Adegbola et al.
2020a). The CAF-QoL covers the three domains of symptoms, effect of current
fistula treatment, and impact on QoL over the last 6 – 8 weeks. The questionnaire
demonstrated good internal consistency, excellent stability, and good responsiveness
and construct validity. The CAF-QoL scale is ready for use as a PROM in research
and clinical practice. It complements objective clinical evaluation of fistula by
capturing impact on the patient.
2.3 Conclusion
Anal fistulae (cryptoglandular of Crohn’s) have a negative impact on QoL.
Patients with recurrent fistula and with secondary extensions had even more
reduced QoL. Validated questionnaires are available and COS are being developed. They should be used to report any outcome of anal fistula treatment.
3 Quality of Life with a Seton and a Fistula
A loose seton is placed to stimulate fibrosis and to condition the fistula tract for
reparative surgery. Cutting setons are placed to strangulate the tract and slowly
transsect the sphincter. Cutting setons should not be used for high anal fistula as
they can cause moderate incontinence (St. Mark’s score of 6–12) in 13.5% of
patients and severe incontinence (score >12) in 8.5% and therefore negatively
impact QoL (Patton et al. 2015).
A seton should be placed loosely and should be comfortable. In a study comparing the comfort drain to a regular silicon drain for complex anal fistula, patients
experienced improved QoL with significant higher median physical and mental
health scores compared with a conventional loose seton (Kristo et al. 2016).
According to the visual analog scale (VAS), patients with a Comfort Drain in situ
reported greater perianal comfort with significantly less burning sensation and
pruritus. Fecal continence was similar in each group. A knot-free seton offers
significant improved quality of life and perianal comfort and could therefore facilitate long-term treatment of complex anal fistula. Many such comfortable drains are
available on the market. However, surgeons still use most frequently vessel loops or
nonabsorbable sutures 4–0or3–0.