Preliminary Report.pdf

Technical Notes Stapled Endorectal Mucosectomy for High Extrasphincteric Fistula-in-Ano: Preliminary Report Francisco Perez, M.D., Antonio Arroyo, Ph.D., Fernando Candela, Ph.D., Rafael Calpena, Ph.D. Coloproctology Unit, Department of Surgery, University Hospital of Elche, Elche, Spain PURPOSE: There is no optimum surgical method of repair for high extrasphincteric fistula-in-ano. We describe a relatively simple procedure for surgery of extrasphincteric fistula, which entirely preserves the anal sphincter, does not interfere with anal function, and does not preclude the possibility of further surgery, if necessary. METHODS: Five patients have been treated for high extrasphincteric fistula with a stapled endorectal flap by using a circular hemor- rhoidal stapler gun. The procedure involved two 180- pursestrings placed above the dentate line and 3 cm apart, proximal and distal to the internal opening. On firing, the result was the excision of a 180- rectal flap, containing the internal ostium, and including rectal mucosa and sub- mucosa. RESULTS: No perioperative complications were encountered. There was some temporary difficulty in con- trolling flatus and/or defecatory urgency in two patients, which spontaneously reversed with no treatment within the first two postoperative months. The mean Cleveland Clinic Score of Incontinence did not vary significantly after surgery. Overall anal manometry did not register any significant differences between preoperative and postoper- ative values. With up to 26 months of follow-up, none of the fistulas recurred. CONCLUSIONS: These preliminary promising results suggest that the stapled endorectal flap could have a role in the management of high extrasphinc- teric fistula-in-ano. [Key words: Extrasphincteric fistula-in- ano; Complex fistula-in-ano; Advancement flap; Rectal mucosectomy] E xtrasphincteric fistulas are usually posttraumatic,secondary to foreign bodies or iatrogenic after previous attempts at fistula surgery. In the