A. Okonkwo1, J. Turner1, A. Chase1, C. E. Clark1 1Morehouse School Of Medicine,Division Of Colon And Rectal Surgery/Department Of Surgery,Atlanta, GEORGIA, USA
Introduction: Fistulo-in-ano has a reported incidence of 31-34%. Non-cutting options for fistula repair are seton placement, endorectal or dermal advancement flaps, fibrin sealant, anal fistula plug, and ligation of the intersphincteric fistula tract (LIFT). Endorectal advancement flap (ERAF) procedures are commonly performed in patients in whom traditional cutting procedures are relatively contraindicated such as high transphincteric fistulas, low transsphincteric fistulas in women and fistula associated with Crohn’s disease. Despite having a reported success rate as high as 75-98%, ERAF is not without complications including flap breakdown, recurrence and fecal incontinence. Traditionally, maintaining a broad base to maintain blood supply has been advocated to reduce flap failure. Here, we report our early experience and outcomes of adult patients who underwent ERAF for complex fistulo-in-ano with the use of intraoperative fluorescence angiography (FA) to reduce complications related to flap ischemia.
Methods: We retrospectively reviewed a prospectively maintained dataset of patients with an age range of 18 to 99 at a single urban teaching hospital who underwent ERAF for complex fistulo-in-ano between July 2014 and June 2016 by board certified Colorectal Surgeons. All procedures that utilized FA were selected for review including 30 and 60 day outcomes. Patients without documented follow up were excluded.
Results:Seven cases were identified with average age and BMI of 37.9 and 25.9, respectively. There were 6 males and 1 female. There were 85.7% of patients who had prior surgery for fistulo-in-ano. No recurrences or complications of any type were noted at 30 and 60 day follow-up. Five of the seven patients (71.4%) required revision of the flap based on intraoperative FA prior to flap fixation.
Conclusion:FA is safe and offers real-time assessment of flap profusion prior to fixation in fistula repair. The rate of flap ischemia may be under estimated and thus intraoperative FA should be considered in the surgical armamentarium to further improve outcomes in ERAF.