Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal vaginal fistulas

Transanal rectal advancement flap (TRAF) is a surgical option in the management of rectovaginal and other complicated fistulas involving the anorectum. Most reported series have a short follow-up. PURPOSE: This study was undertaken to determine the long-term success, safety, applicability, and factors affecting recurrence in patients managed with TRAF, including patients with Crohn's disease. METHODS/MATERIALS: Retrospective analysis of all patients undergoing endorectal advancement flaps at a single institution between 1988 and 1993 was performed. One hundred one patients were identified (70 percent female; 30 percent male). Included were 52 patients with rectovaginal, 46 with anal perineal, and 3 with rectourethral fistulas. Causes were obstetric injury in 13 patients, Crohn's disease in 47, cryptoglandular in 19, mucosal ulcerative colitis in 7, and surgical trauma or undefined causes in 15 patients. RESULTS: No mortality occurred. Median follow-up was 31 (range, 1-79 months). Immediate failure (within one week of the repair) was seen in 6 percent of patients. Statistically (P < 0.001) higher recurrence rates were observed in patients who had undergone previous repairs. Mean hospital stay was four days. Overall recurrence was seen in 29 patients (29 percent). Seventy-five percent of all recurrences occurred within the first 15 months; however, recurrence was noted for up to 55 months after repair. Etiology of fistula, use of constipating medications, antibiotic use, and most importantly associated Crohn's disease did not statistically affect recurrence rates. Failure rate was only influenced by previous number of repairs. CONCLUSION: TRAF is a safe technique for managing complicated anorectal and rectovaginal fistulas, including patients with Crohn's disease. Long-term follow-up is essential to accurately report recurrence rates.